JustCare

Tag: Access

  • Americans want health care system overhaul

    Americans want health care system overhaul

    A new survey of Americans finds utter and complete dissatisfaction with our health care system, reports Amanda Seitz for AP News. Nearly nine in ten Americans say that health care is not handled well or extremely well, including health care for older adults. Most Americans want Congress to overhaul our health care system and think Medicare and Medicaid should be expanded to cover long-term care. They want guaranteed access to care.

    The Associated Press/NORC poll finds that more than half of Americans think the US is not handling health care too well or well at all. Just slightly more than three in ten Americans, 32 percent, think the US handles health care somewhat well. Only 11 percent believe that the US is handling health care for older adults very well or extremely well.

    On top of the dissatisfaction with our health care system writ large, almost 80 percent of Americans worry to some degree about being able to get the care they need when they need it. As it is, tens of millions of Americans are forced to choose between health care and other basic necessities, forcing many of them to forego critical health care.

    As for the cost of prescription drugs, more than nine in ten Americans believe our government is not handling this issue appropriately. How could they? Drug companies are raking in mega profits as millions of Americans die because they can’t afford their medicines. And, though millions of Americans import low-cost drugs from abroad, they are technically forbidden from doing so, even when it could save their lives. Prices abroad can be 90 percent less than in the US.

    What’s the solution? Most Americans–two-thirds–want the federal government to step in and ensure access to care for all Americans. Support for the federal government to step in has grown significantly in the last five years. In 2019, 57 percent thought guaranteeing health care was a government responsibility. In 2017, 52 percent thought so.

    Of course, the simple most cost-effective solution would be for the federal government to negotiate fair prices for health care services, as every other country does, and expand traditional Medicare to everyone. But, only four in ten people polled in this survey supported this solution.

    A majority of people like the idea of a “public option,” allowing people to choose to buy health insurance administered through the government. I once liked it as well…until I came to appreciate how powerful and influential the corporate health insurers are in undermining the public option. We see it today with Medicare Advantage, which is corporate health insurance that has been killing traditional Medicare. Corporate health insurers market and design health plans to attract the healthy, make it difficult for many people to get costly and complex care, and encourage the people with the greatest health care needs to use the public option.

    People too often don’t appreciate that they could get diagnosed with a costly and complex disease or to suffer a major accident in the unforeseeable future. Anything short of comprehensive coverage–one policy that will meet whatever needs you have from whichever physicians you need to see–is a gamble.

    One study, published in June in the Proceedings of the National Academy of Science, found that Medicare for all would have likely saved 338,000 lives lost to Covid-19.

    As Congresswoman Pramila Jayapal tweeted last week, “In the richest country in the world, no one should die or go into debt just because they don’t have access to healthcare.” “We need Medicare for All now.”

    Here’s more from Just Care:

  • Ten ways to improve Medicare Advantage

    Ten ways to improve Medicare Advantage

    Dear Secretary Becerra and Administrator Brooks-LaSure:

    Social Security Works, Just Care USA and Center for Health and Democracy are delighted that the Biden Administration seeks to protect older adults, people with disabilities and the Medicare program from abuses in the Medicare Advantage program. We thank you for the opportunity to comment on ways to improve Medicare Advantage. We agree with the HHS Office of the Inspector General, Government Accountability Office and MedPac that Medicare Advantage is in need of major reform to ensure the health and well-being of enrollees, promote health equity, and minimize legal violations, Including overpayments. As GAO reported: “The Medicare program, which includes MA, is on GAO’s High Risk List, because of its size, complexity, and susceptibility to mismanagement and improper payments.”

    The health insurers offering Medicare Advantage plans have committed many hundreds of legal violations since 2000, and there is reason to believe these will continue unless the federal government overhauls Medicare Advantage. UnitedHealth Group, the company with the most MA enrollees, has paid nearly $600 million in penalties for 332 violations, 300 of which are for consumer protection-related offenses, since 2000. Humana, the second largest MA plan, has paid more than $77 million in penalties for 79 violations, 57 of which are for consumer protection-related offenses, since 2000. CVS Health, the third largest MA plan, has paid more than $1.6 billion in penalties for 463 violations, 236 of which are for consumer protection-related offenses, since 2000. 

    Today, the MA plans have too much incentive and opportunity for abuse. In September 2019, Senator Sherrod Brown, along with five other Senators, wrote CMS requesting answers to questions regarding key failings in Medicare Advantage. To our knowledge, three years later, CMS has not addressed any of the serious issues raised. Unless MA is overhauled on multiple fronts, including revising the way it pays them, Medicare Advantage plans will continue to undermine the integrity of the Medicare Trust Fund, harm health equity, and put millions of their enrollees at serious risk of harm.

    As soon as possible, CMS should stop misdirecting people to believe they can meaningfully choose a Medicare Advantage plan that meets their needs and that they can rely on a misleading star-rating system to choose among MA plans. CMS should:

    • Educate people about the high out-of-pocket costs in MA;
    • Educate people about MA plans’ torturous prior authorization rules;
    • Identify and publicly report the names of MA plans with high rates of delays and denials;
    • Identify and publicly report adjusted mortality rates per MA plan;
    • Terminate contracts with MA plans that are consistently delaying and denying care inappropriately, have high mortality rates, or otherwise are violating their contractual obligations. 

    People from racial and ethnic minority groups, people with disabilities and serious health conditions, people of disadvantaged socioeconomic status, people with limited English proficiency, and people from rural communities disproportionately choose Medicare Advantage because of its low upfront cost. They are, however, at greater risk in Medicare Advantage than in traditional Medicare for two key reasons: 

    Fundamental problems with the current Medicare Advantage model drive health inequities and poor health outcomes for people with complex conditions. The biggest problem is the risk-adjusted capitated payment model. Medicare Advantage plans that: 1. Attract a disproportionate number of enrollees in relatively good health and/or 2. Delay and deny care inappropriately and/or 3. Do not include high quality specialists and specialty hospitals in their networks, can be sure to profit handsomely. The risk-adjusted capitated payment model for MA plans not only hurt vulnerable populations, they drive up Medicare costs. 

    We propose a suite of ten changes to improve health equity, reduce Medicare Advantage threats, enable appropriate CMS oversight, and minimize health insurer violations in Medicare Advantage. 

    1. Change the way the government pays Medicare Advantage plans. 

    The government should pay MA plans so that they do not have a financial disincentive to cover care for people with costly and complex conditions. Prospective payments, unrelated to actual medical claims, create a powerful financial incentive for MA plans to impede access to high-value care for enrollees with complex conditions in order to maximize profits. This is particularly corrosive to health equity:

    • MA plans can maximize profits by enrolling a disproportionate number of people in good health and impeding care for people in poor health. This is one reason why MA plans seldom contract with Centers of Excellence and rarely, if ever, advertise or promote programs for people with costly conditions. 
    • MA plans can maximize profits by underpaying providers. The Texas Hospital Association has identified that “the rapid growth of Medicare Advantage enrollees threatens Texas’ health care safety net. For rural hospitals, Medicare Advantage causes financial instability on an already fragile provider community.” 

    In theory, a risk-adjusted capitated model would pay MA plans enough to cover the cost of services their members need. In reality, however, capitated risk-adjusted models can never ensure access to timely and good quality care for people with costly and complex conditions. In a world in which 50 percent of the Medicare population accounts for less than five percent of spending, such models wildly overpay for the healthy and significantly underpay for the sick.

    Capitated risk-adjusted models create a powerful incentive for Medicare Advantage plans to “cherry pick” the healthy enrollees and “lemon drop” the sick ones. Any Medicare Advantage plan that meets the needs of people with costly conditions — where demand for high-value care is the greatest — is at risk of attracting a disproportionately high percentage of enrollees with costly conditions and suffering financially. Ten percent of people with Medicare with the most serious conditions account for 60 percent of Medicare spending. It makes business sense for MA plans to do what they can to minimize costs from this population. Even good actors must engage in “cherry picking” and “lemon dropping” to ensure they remain financially afloat.

    2. Base payments to MA plans upon the cost of services MA plans cover plus a reasonable fee for administration and a global cap.

    Risk-adjusting capitation payments based upon an MA plan’s own proprietary assessment of the health of its enrollees creates a powerful financial incentive for the plans to “upcode” or attach as many diagnosis codes as possible to its enrollees. The more diagnosis codes, the higher an MA plan’s payments, and the greater the cost to the Medicare program. 

    Upcoding is not simply about bad actors. In order for “good guy” MA plans to compete with “bad guy” MA plans, the good guys are hard-pressed not to engage in upcoding. Otherwise, their competitors have more resources to offer reduced premiums and additional benefits, driving the “good guy” MA plans out of the market. 

    The Department of Justice has identified more than $100 billion of such inappropriate upcoding and overbilling at UnitedHealth Group, Humana, Cigna, Kaiser, Sutter Health and Anthem, among other insurers. It’s anyone’s guess how many additional billions of dollars in overpayments have gone undetected. As a result of upcoding, CMS is projected to overpay Medicare Advantage plans an estimated $600 billion between 2023 and 2031. 

    CMS should acknowledge that it does not have the tools or resources to ensure the diagnosis codes MA plans assign their enrollees are accurate, much less to recoup overpayments. 

    Risk-adjusted capitation adds additional administrative costs and profits to a fee-for-service model. More than 81 percent of MA plans pay all or nearly all their network providers on a fee-for-service basis. Traditional Medicare’s fee-for-service payment model is far more cost-effective and transparent than the MA capitated payment model. Researchers can see what’s working and not working in the health care system, unlike in MA, and drive system improvements. CMS should be building on that payment model.

    3. Require Medicare Advantage plans that pay providers on a fee-for-service basis to use traditional Medicare’s fee schedule. 

    Allowing Medicare Advantage plans to pay lower rates to providers jeopardizes access to care in MA and undermines health equity. Safety net providers serving vulnerable communities, in particular, have little if any leverage to contest MA plan rates and few resources to challenge inappropriate denials of care and coverage, undermining health equity. The Texas Hospital Association has identified that MA plans pay Texas hospitals well below the traditional Medicare rate, which undermines federal payment policies intended to ensure adequate reimbursement for rural hospitals. Medicare Advantage has caused some Texas hospitals to lose several hundred thousand dollars in revenue a year that they had received from traditional Medicare. 

    Conversely, allowing MA plans to pay higher rates than traditional Medicare creates an unlevel playing field with traditional Medicare and drives up Medicare spending needlessly. 

    4. Require MA plans to include all centers of excellence in their networks and disclose out-of-pocket costs for people with complex conditions.  

    The data suggest notable dissatisfaction among MA plan enrollees who need costly care. They disenroll from Medicare Advantage plans at disproportionately high rates in the last year of life and when medical costs are high. A 2021 GAO report suggests that these high disenrollment rates “may indicate potential issues with beneficiary access to care or with the quality of care provided.” In addition, rural enrollees have substantial rates of switching out of Medicare Advantage to traditional Medicare. The data also show widespread and persistent inappropriate delays and denials of care. 

    Until CMS moves away from a risk-adjusted capitated payment model, it must ensure that every MA plan meets the needs of people with the costliest and most complex conditions. Among other things, every MA plan should include all centers of excellence, such as NCI-designated Cancer Centers, in its network. And, rather than allowing MA plans to spend rebate dollars on additional benefits with no evidence of promoting health equity, CMS should consider establishing a mechanism for this money to go towards covering copays and deductibles for people with complex conditions so as to help ensure they are not forced to choose between their rent and their health care.  

    5. Standardize MA coverage rules and cost-sharing design.

    Even the most diligent people with Medicare have no way to select the MA plan that best meets their needs. Each Medicare Advantage plan structures its out-of-pocket costs and out-of-pocket limits in different ways, uses different medical necessity protocols, different referral and prior authorization requirements, designs different networks, and engages in different levels of inappropriate denials of care and coverage. Consequently, some Medicare Advantage plans could literally be harming their enrollees while others could be ensuring timely access to care and delivering good health outcomes. No one can meaningfully differentiate among these plans.

    These structural differences among MA plans, several of which can change at any time, could be disabling or even killing people with Medicare prematurely – and CMS itself would not know. These differences prevent CMS from both protecting enrollees and evaluating MA plans in a meaningful way. At the same time, they prevent people with Medicare from being able to compare MA plans on the most essential metrics. 

    Structural differences also make it all but impossible for CMS to undertake timely and effective audits of MA plans. CMS has not been able to complete timely MA audits from as far back as 2011. Without such audits, CMS cannot protect enrollees in MA plans or hold MA plans appropriately accountable for their bad acts in a timely fashion. CMS should acknowledge that it will never have the tools or resources to appropriately penalize MA plans for bad acts and protect MA enrollees without standardized MA design. 

    People with Medicare today are inadequately protected against proprietary and non-standardized MA policies that could jeopardize their health and well-being. The data show that CMS cannot effectively monitor them for poor outcomes. A 2022 OIG report, a 2018 OIG report, and endless news stories consistently show that Medicare Advantage plans too often inappropriately deny care that traditional Medicare would have covered and that the MA plans should have covered. CMS should require all MA plans to follow traditional Medicare coverage protocols and only allow evidence-based and transparent differences among MA plan protocols. 

    6. Ensure appropriate oversight of MA.

    CMS does not have the tools or resources to ensure appropriate Medicare Advantage oversight and protect enrollees under the current non-standardized model. Standardizing coverage policies would allow CMS to monitor MA plans more effectively and better protect enrollees. Standardized coverage protocols would help ensure MA plans covered medically necessary care and promoted health equity. 

    The GAO has found that CMS has not validated MA patient encounter data as needed and recommended. In a recent House Ways and Means Subcommittee on Oversight and Investigations hearing, MedPAC reported that “After a decade, MA plans are “not producing complete and accurate enough records needed for MedPAC to conduct oversight activities, to understand differences in service use between MA and FFS, to reflect utilization management techniques, and inappropriate denial of covered care.” 

    The failure of Medicare Advantage plans to turn over complete and accurate encounter data for analysis — as required by law — suggests these plans either lack the tools to collect the data or the ability to appropriately manage their enrollees’ care.

    7. Do not assume value in MA, since it cannot be measured. 

    MedPAC has said repeatedly that MA quality cannot be measured. “The current state of quality reporting in MA is such that the Commission can no longer provide an accurate description of the quality of care in MA. With 43 percent of eligible Medicare beneficiaries enrolled in MA plans, good information on the quality of care MA enrollees receive and how that quality compares with quality in FFS Medicare is necessary for proper evaluation. The ability to compare MA and FFS quality and to compare quality among MA plans is also important for beneficiaries. Recognizing that the current quality program is not achieving its intended purposes and is costly to Medicare, in its June 2020 report the Commission recommended a new value incentive program for MA that would replace the current quality bonus program.” Medicare Advantage plans’ higher per enrollee costs than traditional Medicare suggest Medicare Advantage offers less value than traditional Medicare. 

    We know that MA plans spend less money on medical care than traditional Medicare. But, we do not know to what extent they are failing to cover appropriate medically necessary care that traditional Medicare covers. Moreover, industry data on 2018 hospital stays and emergency room visits reveal that Medicare Advantage appears to have greater inpatient use and emergency room visits than traditional Medicare. In a review of the Medicare Advantage studies, Agarwal and colleagues find “the evidence on readmission rates, mortality, experience of care, and racial/ethnic disparities did not show a trend of better performance in MA plans than traditional Medicare, despite the higher payments to MA plans.”

    Assessing MA plan quality is critical for the health and well-being of MA enrollees. Given the poor performance of some MA plans with four and five-star ratings and no information from CMS on bad actors with these ratings, people are at risk of worsened health outcomes if they choose the wrong MA plan. One MA analysis in NBER found that if CMS cancelled contracts with the worst performing five percent of MA plans, it would save 10,000 lives a year.

    To protect people from misleading quality information, CMS should revise its star-rating system, as proposed by MedPAC. It should also eliminate star ratings for all Medicare Advantage plans that do not release complete and accurate encounter data, as required. And, it should consider removing these MA plans from eligibility for the quality bonus program. 

    8. Rethink Medicare Advantage networks. 

    CMS should stop allowing Medicare Advantage plans, except those that are fully integrated health systems, to design their own provider networks and require them to cover care from all Medicare providers. Many if not most MA plans design their networks to minimize their costs and boost their profits to the detriment of the health and well-being of their enrollees. To our knowledge, no independent expert has ever demonstrated the value of a network in Medicare Advantage plans to people with Medicare or the Medicare program other than those in fully integrated health systems. Conversely, stories abound about Medicare Advantage narrow networks that jeopardize access to care and lead to poor health outcomes, particularly for vulnerable populations.

    If the principal reason for a provider network is to contain medical costs, there is no compelling justification for Medicare Advantage plan networks. MA plans generally piggyback off of Medicare rates, which are already relatively low. If MA plans negotiate even lower rates, there’s good cause for concern that providers in their networks are of lesser quality than in traditional Medicare. If the principal reason for a provider network is to ensure good integrated care, it is difficult to appreciate the value of MA provider networks (except in cases where the Medicare Advantage plan is a fully integrated health care system). 

    The risks to the health and well-being of MA enrollees of allowing MA plans to design their provider networks are grave. Compared to traditional Medicare, the data show that MA plans use lower quality home health agencies and nursing homes, and less frequently use higher quality hospitals. They often do not include NCI-designated Cancer Centers or Centers of Excellence. In 2016, the Kaiser Family Foundation found that only 15 percent of Medicare Advantage plans definitely included Cancer Centers and 41 percent definitely did not.

    Plan networks are often so narrow as to delay or prevent people from accessing needed care. They also often undermine continuity of care. And, many MA plans have never had accurate network directories. Plan provider directories are too often misleading and inaccurate. Without accurate directories, network adequacy cannot be established. 

    Moreover, GAO reports that CMS does not assess provider availability to the extent it oversees network adequacy. This failure undermines health equity. Vulnerable older adults and people with disabilities are more likely to go without care when networks are narrow and accessing care with network providers requires significant time and travel.

    We urge CMS to acknowledge that it has neither the tools nor the resources to ensure network adequacy and promote health equity. A 2015 GAO report found “that CMS’s oversight did not ensure that MAO networks were adequate to meet the care needs of MA enrollees. For example, we found that CMS did not adequately verify the accuracy of provider network information submitted by MAOs, and accordingly could not verify whether MAO networks were in compliance with the agency’s provider network criteria.” In June 2022, GAO stated that its recommendations to address these issues “had not yet been fully implemented.”

    To promote health equity, protect people from misleading MA marketing regarding network providers, and ensure access to and continuity of care, CMS should consider requiring MA plans, except fully integrated health systems, to cover care from all Medicare providers. At a minimum, CMS should require those plans that do not keep their directories up to date to open their networks to all Medicare providers. 

    9. Rethink key consumer information regarding Medicare Advantage and overhaul MA marketing to minimize deception. 

    CMS should ensure that people enrolling in a Medicare Advantage plan are able to identify which of those plans are the bad actors, if not cancel contracts with these bad actors. Allowing these bad actors to continue offering MA plans endangers the health of the most vulnerable people with Medicare and undermines health equity.

    CMS also should ensure that no one enrolls in Medicare Advantage without understanding the financial and administrative barriers to care. A recent Center for Medicare Advocacy report found that even the “Medicare and You Handbook” and Medicare website do not explain out-of-pocket costs or prior authorization requirements in a balanced fashion. 

    CMS reported a doubling of MA marketing complaints in the year between 2020 and 2021. Too often people with Medicare have little clue what they are doing when they enroll in a Medicare Advantage plan. CMS’ review of sales calls showed significant confusion among people with Medicare, including “that the beneficiary may be unaware that they are enrolling into a new plan during these phone conversations.”  Of those people who understand differences between traditional Medicare and MA, few appreciate the risks of enrolling in a Medicare Advantage plan.

    10. Level the playing field with traditional Medicare and ensure health equity in MA.

    We urge the government to put an out-of-pocket cap in traditional Medicare so that traditional Medicare is a meaningful choice for everyone with Medicare, including people with low incomes, people in rural communities, people from racial and ethnic minority groups, and people with complex conditions. Without that out-of-pocket cap, the hundreds of thousands of people who face inappropriate delays and denials of care in Medicare Advantage too often are deprived a meaningful choice of traditional Medicare. If they elect traditional Medicare, they expose themselves to too much financial risk because supplemental insurance is unavailable or affordable for them. 

    CMS should consider allowing people in MA to have supplemental coverage that picks up all out-of-pocket costs. Right now, too many enrollees, particularly the most vulnerable, are skipping or delaying critical care because they cannot afford the deductibles and copays, creating substantial health inequities. One NBER study found that a copay increase of as little as $10.40 resulted in thousands of needless deaths. Supplemental coverage would allow people to better budget for their care. Out-of-pocket costs jeopardize the health and well-being of enrollees, with particularly poor outcomes for Latinx and BIPOC communities. In addition, out-of-pocket costs present a large barrier to care for people with low incomes.

    Conclusion

    Medicare Advantage would be significantly improved by:

    • overhauling the Medicare Advantage payment system,
    • meaningfully disclosing MA encounter and other data,
    • holding accountable those MA plans that violate their contracts, 
    • standardizing coverage policies and provider rates, including prior authorization policies, 
    • requiring a broad Medicare provider network, and 
    • overhauling Medicare Advantage marketing practices. 

    Without these reforms, the federal government puts the lives of the most vulnerable people with Medicare enrolled in MA at serious risk and threatens the integrity of the Medicare Trust Fund. It wrongly drives up Medicare Part B premiums for people in traditional Medicare. 

    Traditional Medicare would benefit from some improvements as well, including an out-of-pocket cap on Part A and B benefits and coverage of dental, hearing, vision and long-term care benefits. CMS also needs to end its Direct Contracting/ACO REACH experiment, which involuntarily assigns vulnerable people with Medicare to entities paid upfront to manage their care and is riddled with many of the same grave problems as Medicare Advantage. That said, traditional Medicare generally still provides easy access to necessary care at substantially lower cost than Medicare Advantage, and CMS should ensure that it is a meaningful choice not only for the wealthiest people with Medicare but for everyone with Medicare. 

    We look forward to working with CMS on Medicare improvements. Thank you for this opportunity to share our thoughts. For questions, please contact Diane Archer at [email protected]. 

    Signed,

    Diane Archer, President, Just Care USA

    Alex Lawson, Executive Director, Social Security Works

    Wendell Potter, President, Center for Health and Democracy

  • Four things to think about when choosing between traditional Medicare and Medicare Advantage plans

    Four things to think about when choosing between traditional Medicare and Medicare Advantage plans

    There are four important factors to consider when choosing between traditional Medicare, which is administered by the federal government, and Medicare Advantage plans, which are administered by corporate health insurers that contract with the government: 1. Coverage, 2. Access, 3. Incentives and 4. Cost.
    1. Coverage: Both traditional Medicare and Medicare Advantage plans cover the same benefit package of medically necessary care. But, Medicare Advantage plans typically cover 25 percent fewer services than traditional Medicare because they tend to take a narrow view of what care is medically necessary and profit more the less care they cover. Traditional Medicare covers care from most doctors and hospitals in the United States.  Medicare Advantage plans generally cover care only from doctors and hospitals in their network and, often, only in your area, except in emergencies or urgent care situations. Medicare Advantage plans generally offer some additional benefits. For more information on the fundamental differences between Medicare Advantage fee-for-service plans and traditional Medicare, click here.
    2. Access: With traditional Medicare, you are covered for all medically necessary care without a referral or prior authorization.  For more information on the easy access you have with traditional Medicare, click here. With a Medicare Advantage plan, you often must have a referral from a primary care physician or prior authorization from your Medicare Advantage plan in order for your care to be covered.
    3. Incentives: With traditional Medicare, your doctors and hospitals have every incentive to provide you with all the care they think you need because traditional Medicare will pay for it. That can lead to overtreatment. Medicare Advantage plans receive a fixed amount from the government to cover your care regardless of how much they spend on your care. Consequently, they might offer incentives for their network doctors and hospitals to withhold needed care. The less money a Medicare Advantage plan spends on your care, the more money the Medicare Advantage plan has for its shareholders. To learn more, read this blog post by Diane Archer and Theodore Marmor on the fundamental difference between traditional Medicare and private insurance.
    4. Cost: Traditional Medicare has no out-of-pocket cap, so you need extra insurance to fill coverage gaps. Some people get this additional insurance from former employers, some buy an individual “Medigap” or Medicare supplemental insurance policy and some qualify for Medicaid, which fills gaps, because their income is low.  With this extra insurance, you will have few if any out-of-pocket costs when you get medical or hospital care. You also need prescription drug coverage, if not through Medicaid or a former employer, through a Medicare Part D drug plan. Without this extra insurance, if you need a lot of costly care, your out-of-pocket costs could be astronomical. With a Medicare Advantage plan, you cannot buy extra insurance to fill coverage gaps. So, unless you can afford copays and deductibles, you might have to forgo care. Depending upon the Medicare Advantage plan, you can be liable for up to $7,550 in out-of-pockets costs–copays, coinsurance and deductibles–for your in-network care alone.  If you are in a Medicare Advantage HMO, there is generally no limit to your out-of-pocket costs if you use doctors who are out of network. If you are in a PPO, your out-of-pocket cap can be as high as $11,300.

    For up-to-date advice you can trust, subscribe to Just Care’s free weekly newsfeed here or by clicking the orange button below.

    Here’s more from Just Care on choosing a health plan:

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  • Costs in Medicare Advantage present barrier to care

    Costs in Medicare Advantage present barrier to care

    The Kaiser Family Foundation has a new report that underscores the likelihood of significant access to care issues in Medicare Advantage for people with modest incomes and people in fair or poor health. More people in Medicare Advantage are likely to face challenges affording needed care than people in traditional Medicare with supplemental coverage. To improve and strengthen Medicare, Congress must ensure that out-of-pocket costs are not a barrier to care for older and disabled Americans.

    Medicare Advantage plans have done a great job of enlisting people to join their ranks. Many people opt for Medicare Advantage over traditional Medicare because Medicare Advantage has an out-of-pocket cap, albeit one that can be as high as $7,550. Because traditional Medicare does not have an out-of-pocket cap, to protect yourself from astronomical out-of-pocket costs, you need to buy a Medigap policy or retiree coverage, or you need Medicaid.

    More people with low incomes choose Medicare Advantage over traditional Medicare, including more Black people and more Hispanic people because it has an out-of-pocket cap. But, overall, more people report cost-related problems in Medicare Advantage than in traditional Medicare because traditional Medicare with supplemental coverage minimizes people’s out-of-pocket costs. The nearly six million people in traditional Medicare without supplemental coverage experience the highest rate of problems related to out-of-pocket costs.

    Black people enrolled in traditional Medicare with some form of supplemental coverage, be it Medigap, retiree coverage or Medicaid, had fewer cost issues relating to their care than Black people in Medicare Advantage. Nearly one in three (32 percent) Black people enrolled in Medicare Advantage, said they had cost-related problems as compared with around one in four of them in traditional Medicare (24 percent).

    More than one in four (28 percent) of Black people living in their communities faced cost-related problems. That is twice the rate of White people experience cost-related problems (14 percent). And, cost problems were 50 percent greater for Hispanic people living at home–21 percent–than White people–14 percent. People with incomes of $40,000 or more had the fewest cost-related issues–eight percent.

    Overall, people in traditional Medicare with supplemental coverage had fewer cost-related problems than people in Medicare Advantage, 12 percent v. 19 percent. But, 30 percent of people in traditional Medicare without supplemental coverage, about 1.5 million people with Medicare, had cost-related problems. About 22 percent of Black people in traditional Medicare lack supplemental coverage, almost 50 percent more than White people, 15 percent of whom lack supplemental coverage.

    People who report themselves to have fair or poor health had lower rates of cost problems in traditional Medicare than in Medicare Advantage, 31 percent v. 39 percent. Cost-related problems are most grave for Black Americans in fair or poor health, who are enrolled in Medicare Advantage. Half of them faced cost-related problems. By comparison, one-third of people in traditional Medicare who report themselves to have fair or poor health faced cost-related problems. People in traditional Medicare with supplemental coverage who report themselves in fair or poor health had the lowest rate of cost-related problems, though still considerable. More than one in four of them (27 percent) had cost-related problems.

    The Kaiser Family Foundation does not define “cost-related problems.” But, whatever form they take, they present a barrier to care. People skip care because of cost or they get care and then struggle to make ends meet, leading them to think twice before they next get care.

    Here’s more from Just Care:

  • Coronavirus: How many Medicare Advantage members went without treatment?

    Coronavirus: How many Medicare Advantage members went without treatment?

    A new study in the American Journal of Preventive Medicine looks at out-of-pocket costs for people in Medicare Advantage plans and how they affect access to care. There is inexcusably little information available on what you will pay on average out of pocket in a particular Medicare Advantage plan in a given year, let alone for specific services. This study reports that some Medicare Advantage plans voluntarily paid the full cost of care for hospitalized members with COVID-19–although it does not say how many–and is concerned about Medicare Advantage plan members who went without COVID-19 treatment because of the out-of-pocket costs.

    To get a sense of what people in Medicare Advantage would pay for COVID-19 treatment, researchers looked at 2018 data to determine how much out-of-pocket costs could be for people hospitalized with the flu. The researchers found that of 14,278 people in a Medicare Advantage plan over 65, hospitalized with the flu in 2018, paid an average of $989 on deductibles, copays and coinsurance. Hospitalizations averaged around six days. Averages are a bit misleading as there were a small group of people in certain Medicare Advantage plans whose out-of-pocket costs were far higher. We don’t know which Medicare Advantage plans charged more and which charged less.

    Congress did not mandate that Medicare Advantage plans cover the full cost of COVID-19 treatment, only testing. It is not clear why it did not insist on full payment for COVID treatment given that out-of-pocket costs undermine access to needed care. It should not have cost more; the federal government was overpaying Medicare Advantage plans, paying them as if people were using the typical number of health care services at a time when they were using far fewer health care services.

    The researchers believe that it is critical that Medicare Advantage plans cover the full cost of COVID-19 treatment to ensure that everyone who needs care receives it. In 2018, four in ten people did not have $400 in the bank to pay for an emergency.

    Of note, the researchers only looked at some Medicare Advantage data and were unable to know for nearly three in four people studied whether they were enrolled in a Medicare HMO or Medicare PPO. The data is incomplete.

    Here’s more from Just Care:
  • Access to affordable care improves when people enroll in Medicare

    Access to affordable care improves when people enroll in Medicare

    A new paper in Health Affairs by Paul Jacobs looks at the impact of Medicare on access to affordable care. It finds that enrolling in Medicare–be it traditional Medicare or Medicare Advantage–improves access and affordability of care for people turning 65. It further finds that expanding Medicare to people under 65, as President Biden and others have proposed, is likely to provide better access to affordable care than their private insurance options.

    Today, people with Medicare say that they have about the same or better access to care as people with private insurance. They also do not have problems finding a new doctor. This is particularly noteworthy as people with Medicare use a lot more health care services than people under 65.

    Jacobs reports that about 15 percent of people age 57 do not have a usual source of care as compared with 6.3 percent at age 72, thanks to Medicare. And, 6.3 percent of people age 64 had difficulty getting needed care because of cost as compared to 3.7 percent of people age 66.

    That 2.6 percent increase in ease of getting care for people with Medicare translates to 22.1 percent more people having a usual source of care once on Medicare. And, 50.9 percent more people were able to get needed care once on Medicare. Affordability of care also improved significantly for people enrolling in Medicare. At age 66, 46 percent more people could afford to get care.

    Jacobs did not find any subpopulation with worse access or affordability once enrolled in Medicare. Access and affordability of care improved for everyone. That said, white Americans and Hispanics had greater improvements to access and affordability than non-Hispanic Black Americans. White people and Hispanics also had fewer delays in care because of the cost than non-Hispanic Black Americans.

    Jacobs remarks on Medicare’s great strengths as compared to private insurance. He notes that it would not have been surprising to find access issues with Medicare given that Medicare payment rates tend to be significantly lower than private insurance rates. But, people with Medicare did not have trouble finding doctors nor did they face delays getting care. He further notes that it would not have been surprising to find an increase in affordability issues given that older adults use more health care services and have lower incomes than younger adults.

    Based on the study results, if the goal is to improve access and affordability of care, it would be a mistake to raise the age of Medicare eligibility, as many Republicans propose. Rather, we need to improve and expand Medicare to everyone.

    Here’s more from Just Care:

  • People with low incomes struggle to access care in US

    People with low incomes struggle to access care in US

    The United States rations care based on ability to pay, creating severe health inequities. People with low incomes in the US are more likely to suffer from chronic conditions and struggle to access care than people in other wealthy nations. The Commonwealth Fund found income-related disparities are prevalent in nearly all 11 high-income countries it studied, but health disparities based on income are the worst in the US. 

    People with low incomes in the US suffered from greater income-related disparities than people in the other 10 countries. In the US, more than one in three people with low-incomes has at least two chronic conditions. Other advanced nations also indicate greater chronic conditions among people with low incomes.

    That said, in the US, about one in three people with low incomes suffer from anxiety or depression, more than every other country except Australia and Canada. People in Germany and Switzerland were least likely to suffer from anxiety and depression. Fewer than one in six of them suffer from these conditions.

    Disparities based on income in the US are evident in all key aspects of life. More than one in four (28 percent) people with low incomes worry about their ability to pay for housing, food and other fundamental needs. In other countries studied, between six and 22 percent reported these worries.

    One in two people in the US with a lower income skip care, including visits to the doctor, tests, treatments and prescription drugs because of how much it costs. In other advanced nations such as Germany, Norway, the UK and France, around one in eight people with low incomes skip care because of how much it costs.

    More than any other advanced nation, people in the US struggle to pay bills for their health care. More than one in three people with lower incomes in the US (36 percent) face difficulty. In other nations, between one in six and one in 14 face difficulty.

    In the US, many adults with low incomes don’t have a primary care doctor or place to go to get their care. And, only about 40 percent of them are able to get care the day or day after they try to get it. In Germany and the Netherlands, more than 60 percent of people can get same day or next day care.

    And, just 58 percent of people with low incomes in the US are able to get care after hours. Forty-five percent of Americans with low incomes go to the emergency room for needed care in cases in which they could have simply gone to the doctor’s office had they had access to a doctor.

    Health care is a human right. Everyone regardless of income in the US, the wealthiest country in the world. should be able to go to the doctor and get the care they need without worry about the cost. Shouldn’t the US do at least as well by its citizens as New Zealand, Germany and Japan?

    Here’s more from Just Care:

  • Trump administration attempts to privatize traditional Medicare

    Trump administration attempts to privatize traditional Medicare

    The Trump administration is deep into rolling out a pilot plan that, over time, could privatize the public fee-f0r-service Medicare program unless the Biden administration hits the pause button on its implementation. Several open issues with this payment and care delivery or “Geo” model–a capitated payment system–highlight its ability to undermine access to care for millions of older and disabled Americans who might be forced into it.

    1. How can CMS ensure that capitated corporate plans regulating access to care for people in traditional Medicare won’t undermine quality of care or increase costs? Government audits indicate that capitated corporate Medicare Advantage plans systematically engage in widespread inappropriate delays and denials of care. They also overcharge the government for their services to the tune of billions of dollars a year. And, MedPac continues to report that taxpayers are paying more for them on a per capita basis than for people in traditional Medicare. Moreover, Medicare Advantage plans have not released accurate and complete encounter data, as required by law, which would allow a meaningful assessment of each of them.
    2. How will CMS effectively assess quality based on consumer surveys and “measuring outcomes?” Information from people who are relatively healthy is of little relevance as they don’t use the health care system much. The 20 percent of people with Medicare who are very ill or who need complex care will likely be unable to assess and report the quality of care they receive.
    3. How will the government know whether the GEO model improves quality without increasing costs over the short and long-term? How will CMS uncover fraud, detect inappropriate care, or identify practices that harm patients without this data?The model does not provide for a meaningful way for CMS to oversee the direct contracting entities (DCEs) that will be assuming full financial risk for all medical and hospital services people receive. It does not call for the DCEs to turn over encounter or claims data. 
    4. What protections will be available to people in Medicare who are forced into the GEO model if they are unable to get the care they need? The model does not allow them to opt out. Their out-of-pocket costs should not increase, but how will CMS know if they do?
    5. CMS suggests that the DCEs, corporations assuming full financial risk, can use “value-based” payments to providers. How will DCEs determine value-based payments? Will these payments lead physicians to delay and deny people needed care?
    6. Some people with Medicare need a substantial amount of care during the course of the year.  How will CMS know whether people with complex and costly conditions are getting the care they need rather than low-quality ineffective care or no care at all?
    7. Given that Medicare rates are already significantly lower than commercial rates, does CMS believe that high-quality providers will accept lower rates from DCEs? 
    8. How will CMS know whether DCEs are fostering health inequities, rationing care based on ability to pay and ability to navigate their complex system?
    9. What assurances are there that DCEs wouldn’t end up behaving like chain nursing home owners, pocketing the vast share of their government payments and leaving our nation’s most vulnerable people without access to care? How will they be held accountable if they do? Even if CMS were able to analyze every aspect of DCEs, DCEs can change their methodologies as they please when they please. 

    Everyone wants a healthcare system that improves quality and reduces costs. But, conducting this large scale costly social experiment with vulnerable older adults and people with disabilities seems imprudent and misguided at best.

    Here’s more from Just Care:

  • Coronavirus: Doctors and nurses reconsider their professions

    Coronavirus: Doctors and nurses reconsider their professions

    The novel coronavirus has taken a huge toll on the lives of millions of Americans, particularly health care workers and other essential workers. Kaiser Health News reports on how some doctors and nurses are responding to this pandemic. The news is not pretty; it’s easy to imagine a future with robots as healthcare providers.

    Many nurses are fighting back against low-wage jobs that put them at risk. Their small hospital salaries are not enough to make the risk of catching COVID-19 worth it. They are leaving these steady hospital jobs for far higher paying jobs that guarantee them the personal protection they need.

    And, they are taking jobs that pay thousands of dollars a week to provide care to people in their homes. Working as private pay nurses, they can earn more than $6,000 a week. In some cases, they can earn $10,000 a week. By the hour, their base rate is $95. But, their jobs are not secure and do not come with health insurance.

    These traveling nurses will go wherever they are needed. And, their ranks are rising rapidly, now at 50,000. Just two years ago, there were 31,000.

    The result is a hospital crisis. And, greater health inequities. The hospitals in poor areas generally can’t afford to attract the nurses they need. Rural hospitals and public hospitals in urban areas are finding themselves understaffed. They don’t have the health care workers they need to provide care to COVID-19 patients.

    And, because COVID-19 is surging throughout the country, there are few areas with an extra supply of nurses.

    The good news is that finally nurses are commanding fair wages. The bad news is that some of them now command wages that most hospitals and individuals cannot afford.

    At the same time, thousands of doctors’ offices have been forced to close. With COVID-19, many primary care doctors saw a sharp drop in their patient volume. With that, came a major loss of revenue. As it is these doctors tend to earn a lot less than specialists, averaging less than $200,000 a year.

    Consequently, there are too few primary care doctors. This new wave of closures is only making it more difficult for people to get needed care.  It puts many of them with chronic conditions at increased health risk.

    Pre-novel coronavirus, we had a shortage of some 15,000 primary care doctors. According to the Health Services Research Administration, about one in four Americans live in an area where there is a a shortage of health care workers.

    One survey found that about one in twelve doctors’ offices have closed as a result of the novel coronavirus. That’s about 16,000 offices. The doctors say they do not have the financial means to remain open.

    Here’s more from Just Care:

  • Medicare Advantage: Will you get care from the doctors you want to see at a price you can afford?

    Medicare Advantage: Will you get care from the doctors you want to see at a price you can afford?

    It’s Medicare Open Enrollment season in the midst of a novel coronavirus pandemic. If you have Medicare, you should be checking out your options for 2021. And, if you’re planning to remain in a Medicare Advantage plan–a private insurance plan that contracts with the government to offer Medicare benefits–or considering enrolling in one, it’s especially important to look at the tradeoffs you will be making. Once you’re enrolled in a Medicare Advantage plan, it can be far more challenging and costly to get the care you need than in traditional Medicare.

    For sure, it’s simpler to enroll in a Medicare Advantage plan than traditional Medicare, public insurance administered directly by the federal government. With Medicare Advantage, there is an out-of-pocket cap, and you can’t buy supplemental coverage to fill gaps. Also, as a general rule, your prescription drug coverage is included with your medical coverage, so you don’t have to buy a separate policy.

    But, it’s harder to leave a Medicare Advantage plan than traditional Medicare. In most states, insurers that fill gaps in traditional Medicare, Medicare supplement insurers or “Medigap,” are not required to sell you this coverage except when you first enroll in Medicare or you move. (There are a few other exceptions.) And, many people who need costly health care services, such as home care, nursing home care, or specialty care, find they are far better off in traditional Medicare.

    Also, with Medicare Advantage, in 2021, your out-of-pocket costs for in-network care can be as high as $7,550, which the Medicare Handbook fails to mention. On top of that, you have out-of-pocket costs for your prescription drug coverage. In addition, you are restricted in the doctors and hospitals you can use and often need permission from your Medicare Advantage plan–“pre-authorization”–in order to be covered for specialty tests.

    A report from the Kaiser Family Foundation finds that more than three in four people enrolled in a Medicare Advantage plan have restricted access to doctors and hospitals. On average, plans offered them access to less than half the physicians in their area. Your access to care depends significantly on where you live and the plan you choose. Fewer than one in four people are enrolled in broad-network Medicare Advantage plans, offering access to at least 70 percent of physicians in the community.

    Access to certain types of specialists can be especially restricted in a Medicare Advantage plan. Kaiser found that some plans offer very little choice of certain types of specialists. What’s worse is that it is virtually impossible to know in advance whether you will have access to the doctors you want to use. And, while you might be healthy when you join the Medicare Advantage plan, the whole reason to have health insurance is to protect you in the event that you develop a complex condition and need costly services.

    Kaiser looked at 391 Medicare Advantage plans in 20 counties. Its findings assume that the Medicare Advantage provider directories were accurate and that the physicians listed were taking new patients. Other studies have found these provider directories to be wildly inaccurate, and often, providers are not taking new patients.

    Here’s more from Just Care: