Tag: Care coordination

Primary care in Medicare Advantage: A crapshoot
Don’t join a Medicare Advantage plan because you believe it will offer good primary care. According to a new report by the Commonwealth Fund, primary care could be good and it could be bad in Medicare Advantage, depending upon the plan you are enrolled in and the primary care physician you use. What’s for sure is that if you get sick and need costly care, you are taking a huge gamble with your health in Medicare Advantage.

For sure, some if not most insurers offering Medicare Advantage plans want you to see a primary care doctor. That’s how they can most easily add diagnoses codes to your medical records in order collect more money from the government for your care. But, it’s not clear whether seeing a primary care physician in Medicare Advantage will improve your health or not.

We know very little about whether a particular Medicare Advantage plan will ensure a primary care doctor coordinates your care in ways that keep you healthy. The government pays Medicare Advantage plans upfront regardless of whether they coordinate care. So, they could advise their primary care doctors to spend little time with you or pay these physicians more if they don’t refer you for specialty care or refer you to specialists who cost less and provide lower quality care.
The Commonwealth Fund examined whether primary care physicians treat Medicare Advantage patients in different ways from physicians who treat Traditional Medicare patients. They found that, overall, there were not many meaningful differences between the care primary care physicians provide patients in Traditional Medicare as compared with the care they provide patients in Medicare Advantage.

Unfortunately, “overall,” is not really helpful in this analysis. It’s like saying that “overall” restaurants in NYC are fine. The question for people with Medicare is which are the good Medicare Advantage plans and which ones should be avoided. This Commonwealth Fund survey does not provide that information.

In short, it seems not to be the case that insurers are making it easier for their primary care physicians in Medicare Advantage to manage and coordinate care than Traditional Medicare.

Here’s more from Just Care:

Six reasons you need a primary care doctor in this age of specialization

Four questions to ask yourself about your primary care doctor

Five tips for talking to the people you love about their health

2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan

Get the preventive care you need: Medicare pays for it
March 25, 2024
Most Medicare Advantage plans will see lower star-ratings
Robert King writes for Fierce Healthcare about a change to Medicare’s star-rating system for Medicare Advantage plans. As a result of Medicare’s change to its star-rating system, a new analysis finds that the overwhelming majority of Medicare Advantage plans will face lower star-ratings.

For some time now, the federal government has tried–unsuccessfully–to help people distinguish among Medicare Advantage plans–corporate health insurance plans that are paid to cover Medicare benefits. Medicare Advantage plans are an alternative to traditional Medicare, which is public health insurance that covers your care from most doctors and hospitals across the US and is administered directly by the federal government.

The government uses a “star-rating” system to help people distinguish among Medicare Advantage plans. But, the stars the government gives Medicare Advantage plans are no way to gauge whether a Medicare Advantage plan will cover your care from physicians you trust when you need it. From the perspective of people with Medicare, the stars are a farce because the Medicare Advantage plans have been able to game them and they do not measure key differentials among Medicare Advantage plans. For example, the star-rating system does not factor mortality rates in different Medicare Advantage plans and rates of inappropriate delays and denials of care.

The Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare, is now raising the bar for getting stars in 2023. It will be giving double the weight it has to customer service, accessing prescription drugs, care coordination and health care quality.

Under this new way of calculating star-ratings, nearly 50 percent of Medicare Advantage plans would lose one star. The loss of a star speaks to the difficulty that enrollees are increasingly facing getting prescription drugs in their Medicare Advantage plans. More Medicare Advantage enrollees are unsatisfied with their ability to fill their prescriptions at a reasonable out-of-pocket cost.

From the Medicare Advantage plans’ perspective, losing a star or two means loss of significant revenues, often millions and sometimes billions of dollars. Without that money, Medicare Advantage plans might not be willing to offer as generous benefits. It will also be harder for them to retain enrollees.

More than four in ten (44 percent) Medicare Advantage plans could lose a star because their enrollees are less satisfied with customer service and care coordination.

Press Ganey performed the analysis in early 2022, based on data from 446 Medicare Advantage plans.

Since 2015, Medicare Advantage plan quality bonuses have nearly quadrupled, from $3 billion to $11.6 billion. Part of the increase is attributable to the government awarding bonuses to more Medicare Advantage plans. Part of the increase is attributable to the number of enrollees in the Medicare Advantage plans that received bonuses.

Here’s more from Just Care
June 7, 2022
Seven questions to ask before scheduling a house call with a doctor you don’t know
Without a doubt, many of us would prefer a house call from a friendly primary care doctor than a trip to the doctor’s office or, if necessary, the emergency room. And, people with chronic and disabling conditions in particular may find it hard to leave home to visit the doctor. With no doctor available to make a house call, many older adults skip needed care and end up in hospital or, worse still, having an ambulance take them to the emergency room.

With the right medical team, house calls can be a good alternative to an emergency room visit. Indeed, house calls are on the rise for people with Medicare, up 40 percent between 1998 and 2004. And, in 2013, Medicare paid for more than 2.6 million house call visits. Medicare pays for home health care services from Medicare-certified home health agencies in some cases when a patient is homebound and for hospice care at home in some cases when a patient is terminally ill.

Medicare is now in the midst of a small demonstration project to determine whether house calls for patients with chronic conditions can improve care and save money. If you or someone you love is not participating in that demonstration project or cannot find a doctor you know to make a house call, one emerging health care business makes it easy to summon a doctor for a house call via a smartphone app.

Before scheduling a house call with a doctor you do not know, check in with your primary care doctor. You want to make sure that the doctor who makes the house call will meet your needs. Here are seven questions to ask:
1. Will the doctor provide quality care? Find out whether the doctor is board certified in internal medicine or family practice medicine. Also, check out the doctor with your local hospital, health system, Area Agency on Aging or other community resource. If they are not familiar with the doctor, they might have a doctor who makes house calls to recommend.
2. Will the doctor take the time to understand your medical conditions, including current medications, allergies and chronic conditions?
3. Is the doctor part of a medical team that includes nurses, therapists, social workers and pharmacists who can provide additional support?
4. Is the doctor bringing portable diagnostic equipment and medical supplies to properly diagnose your condition?
5. Will the doctor assess the home environment for safety and health risks?
6. Will the doctor develop a plan of care and be in touch with your primary care doctor to coordinate your care?
7. Will you need to pay out of pocket or will Medicare reimburse for this service? Ask whether the doctor accepts Medicare. If the doctor accepts Medicare, traditional Medicare should pay and your charges should be capped. If you’re enrolled in a Medicare Advantage plan, call the plan to see whether there are in-network providers who make house calls.
For more information about the advantages of house calls and what you need to think about, read this publication by Leading Age.
August 20, 2015