JustCare

Tag: Choice

  • To protect older adults and people with disabilities, Congress must add an out-of-pocket cap to Traditional Medicare

    To protect older adults and people with disabilities, Congress must add an out-of-pocket cap to Traditional Medicare

    To promote health equity, meaningful choice, competition between Traditional Medicare and Medicare Advantage plans, as well as to protect older adults and people with disabilities, Congress should limit people’s out-of-pocket expenses in Traditional Medicare by adding an out-of-pocket cap. Congress also should eliminate the enormous overpayments to Traditional Medicare in order to ensure the sustainability of the Medicare Trust Fund and bring down Part B premiums.

    Health equity:  People of color and people with limited means are usually forced to choose among Medicare Advantage plans without being able to know which will cover their care appropriately. They are at serious risk. They are often locked into Medicare Advantage plans with very narrow networks and excessive prior authorization requirements because Traditional Medicare does not have an out-of-pocket limit and they cannot afford supplemental coverage.

    Medicare Advantage insurers are able to decide which Medicare Advantage plans offer more or fewer prior authorization requirements and better provider networks; but, there’s no way for consumers to know. The Medicare Advantage star-rating system is a farce; five-star plans can be bad actors, with ghost networks and widespread inappropriate delays and denials of care. The Centers for Medicare and Medicaid Services (CMS) has no way to protect vulnerable Medicare Advantage enrollees. Without an out-of-pocket cap in Traditional Medicare, they generally do not have it as an option.

    Choice: An out-of-pocket cap in Traditional Medicare would give people a meaningful choice of Traditional Medicare. It would allow people to enroll in Traditional Medicare without financial risk. Low and middle-income people and people of color lack this choice today because they cannot get the supplemental coverage they need to protect themselves financially. Supplemental coverage is either unaffordable or unavailable. 

    Indeed, today, people living in communities that insurers do not see as profitable, typically lower-income communities, can be left without any MA plan options and no meaningful Traditional Medicare option.

    Competition: An out-of-pocket cap would help level the playing field between Traditional Medicare and Medicare Advantage, driving competition.

    Cost savings: In 2024, Medicare Advantage plans cost as much as 22 percent more per person than Traditional Medicare, eating into the Medicare Trust Fund and driving up Part B premiums. Traditional Medicare is far more cost-effective than Medicare Advantage. An out-of-pocket cap in Traditional Medicare would enable more people to enroll, reducing Medicare spending.  

    Coverage: An out-of-pocket cap would protect people in Medicare Advantage plans who are too often inappropriately denied the reasonable and necessary services to which they are entitled. It would enable them to switch to Traditional Medicare. Today, the government cannot protect them from bad actor Medicare Advantage plans. The most vulnerable Medicare subpopulations are hardest pressed to navigate the rules and narrow networks in Medicare Advantage and get the care they need. 

    Here’s more from Just Care:

  • AMA asks Congress for help saving independent medical practices

    AMA asks Congress for help saving independent medical practices

    In a Statement to Congress, the American Medical Association (AMA) asks for help saving independent medical practices. The AMA wants higher physician pay and government intervention to address systemic inequities and administrative burdens, recognizing the calamitous state of our health care system. “This is not just a call for action; it is a plea to safeguard the heart of American health care before it is too late.”

    What’s concerning is that the AMA does not call out the significant role of corporate health insurers in destroying our health care system. The AMA appears to like the higher rates the physicians receive from corporate insurers and doesn’t want to give those up; rather, it wants higher Medicare rates.

    The AMA highlights many big health care problems, without attribution to the insurers. The practice of medicine is not what it used to be. Small independent practices are vanishing. In their place, big corporations are buying up physician practices and intervening in the practice of medicine. (UnitedHealthcare, for example, now controls 10 percent of physicians in the US.)

    Physicians are increasingly no longer free to make treatment decisions for their patients. Rather, insurance companies second-guess their decisions, coming between them and their patients. The consequences can be dire for the patients, as the data indicates. The AMA also recognizes the need for “expanded support for rural and underserved areas” and “a health care infrastructure secured from emerging threats.”

    Of course, it’s the insurers who are responsible for the bulk of our health care system’s failings. They implement prior authorization protocols that harm providers and patients alike. But, while the AMA doesn’t like these protocols, it’s letter to Congress makes it seem as if the insurers are forced to use prior authorization: “This requirement for insurers to approve treatments before they can be administered not only delays diagnosis and treatment but also involves substantial paperwork and diverts critical resources and time that could be better spent on direct patient care.”

    The AMA only indirectly calls out insurers for their role in underpaying providers, undermining competition and patient choice. After all, it’s the insurers who are failing to pay rural and other hospitals appropriately for the care they provide, threatening their very being, forcing many to close, and making it harder for people to access care.

    The question is whether the AMA will ever join forces with patients to call for guaranteed affordable health care for all. Until then, it will be hard to move Congress to overhaul our health care system.

    Here’s more from Just Care:

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

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

    The Annual Medicare Open Enrollment period begins October 15 and ends December 7. If you have Medicare, you are likely to see endless ads and receive lots of mail from an assortment of insurers chomping at the bit to get you to sign up with one of their Medicare Advantage plans. That’s how they rake in the big bucks, tens of billions of dollars a year. Unfortunately, our government does a poor job of helping you to understand differences between traditional Medicare, which is administered by the Centers for Medicare and Medicaid Services (CMS), and Medicare Advantage plans, which are administered by corporate health insurers that contract with the government. And, you can’t trust the corporate health insurers or their sales agents to tell you what you need to know.
    There are five basic differences between Traditional Medicare and Medicare Advantage that you need to understand.
    1. Coverage:
    Traditional Medicare. With traditional Medicare, you are covered for the medicallyreasonable and necessary care your providers believe you need. An insurance company is not second-guessing your doctors.
    Medicare Advantage. Medicare Advantage plans are supposed to cover the same benefits as traditional Medicare, but they cover significantly fewer, as has been documented over and over again. They often engage in widespread inappropriate delays and denials of care and generally require you to get approval before they will pay for most costly services. That’s how they maximize profits. If you think you might get sick or need costly health care at some point, even if you don’t need it now, think twice before signing up with a Medicare Advantage plan. No one provides you with the information you need to know to distinguish the good Medicare Advantage actors from the bad ones. And, there appear to be a lot of bad ones.
    2. Health care providers:
    Traditional Medicare. With traditional Medicare, you can see almost all doctors and use virtually all hospitals anywhere in the United States. Almost all take Medicare and more than 90 percent “take assignment,” accept Medicare’s approved charge as payment in full. The most they can charge is 15 percent above that amount.
    Medicare Advantage. With Medicare Advantage, your care is generally only covered when you use “in-network” providers. They can be few and far between and are often only located in your community. If you travel or spend time away from your primary residence, a Medicare Advantage plan usually will not cover your care, except in emergencies, Also, you might find that the providers in their directories are not taking new patients or have left the network. So, if you are thinking of joining a Medicare Advantage plan or are in one now, talk to any of the doctors you know you want to continue seeing to confirm that you will still be able to have your care covered when you see them. Keep in mind that a lot of the Medicare Advantage plans have lower quality providers in their networks and might not have a cancer center of excellence as part of their network.
    3. Costs:
    Traditional Medicare. With traditional Medicare you must pay your Part B monthly premium. You are generally liable for a hospital deductible and 20 percent of the cost of your medical care, unless you have supplemental coverage, either Medigap, which you buy in the individual market, Medicaid, or retiree coverage from a former employer. If you have supplemental coverage, most if not all of your costs will be covered. Traditional Medicare does not have an out-of-pocket maximum.
    Medicare Advantage. With Medicare Advantage, you pay your Medicare Part B premium and you might have no additional premium, but your out-of-pocket costs can be sky high. You cannot buy supplemental coverage to pick up your out-of-pocket costs. Your costs turn on the Medicare Advantage plan you choose, the care you need, and what the Medicare Advantage plan charges you for your care. You generally will have to pay a copay when you are hospitalized or need medical services. Your out-of-pocket costs can be over $8,000 for in-network care alone if you need costly care. But, each Medicare Advantage plan has its own out-of-pocket maximum. If you go out-of-network for your care, you will be liable for the full cost of your care, unless you are in a PPO (preferred provider organization), in which case you generally will be liable for 40 percent of the cost.
    4. Drugs:
    Traditional Medicare. With traditional Medicare, you will need to buy Medicare Part D prescription drug coverage if you want drug coverage. That typically costs about $55.50 a month.
    Medicare Advantage. With Medicare Advantage, your drug coverage is usually included in your plan’s monthly premium.
    Whether you’re in traditional Medicare or a Medicare Advantage plan, be sure to look at differences in your drug costs among Medicare Part D drug plans. And, keep in mind that it is possible, even likely, that you might spend less getting some of the drugs you take from Costco or another mail-order pharmacy than paying the copay for them through your Part D plan. Part D plans can have higher copays than the total cost of the drug from a low-cost pharmacy.
    5. Quality:
    Traditional Medicare. If you want control over the quality of your health care providers, you probably want to be in Traditional Medicare, where you choose the providers you see.
    Medicare Advantage. In a Medicare Advantage plan, the plan restricts your access to providers. And, even when you see a provider you want to see, the Medicare Advantage plan might not let your physician or hospital provide the care that they think is best for you. For example, if your doctor thinks you need 50 days of inpatient rehab therapy, your Medicare Advantage plan still might decide you only need 10 and will only cover 10 days.

    Bottom line: With traditional Medicare, your doctors and hospitals have every incentive to provide you with all the care they think you need and traditional Medicare will cover it. 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 have an incentive to withhold needed care and to incentivize their physicians to limit the care they provide you. The less money a Medicare Advantage plan spends on your care, the more money the Medicare Advantage plan has for its shareholders. Since there’s no good data to distinguish the good Medicare Advantage actors from the bad ones, you are gambling with your health and well-being when you enroll in a Medicare Advantage plan. To learn more, read this blog post by Diane Archer and Theodore Marmor on the fundamental difference between traditional Medicare and private insurance.

    Here’s more from Just Care:

  • Does your Medicare Advantage plan deny care frequently? Who knows

    Does your Medicare Advantage plan deny care frequently? Who knows

    Robins Fields reports for Pro Publica on the serious challenge facing anyone, including people with Medicare, trying to choose health insurance. There is no way for them to know which corporate health plans deny care frequently; some of these health plans have super high denial rates that can put the health and well-being of their enrollees at risk. So, if you’re choosing among Medicare Advantage plans, the corporate health plan alternative to the government-administered traditional Medicare option–which has a very low denial rate– beware.

    As Fields explains in her story, people need to know about health plan denial rates in order to make an informed choice. After all, you’re buying insurance to ensure that when you need care, you can get it and, when you need care urgently, you can get it swiftly, without worry about the cost. But, even though reports show that some health plans deny as many as one in three requests for coverage, jeopardizing access to care for people in those plans, you can’t know which ones those are.

    The problem of not knowing about Medicare Advantage plan denial rates is most acute when you are diagnosed with a complex and costly condition and need a lot of care. Will you get to the oncologist before your cancer spreads? Will your health plan even cover the tests you need to see whether you have cancer?

    Fields tried to get the information on health plan denial rates without any success.  What’s so troubling is that this information should be easily accessible but neither the federal government nor state governments have tried to correct it. Pro Publica has already exposed how top insurers deny claims speedily and even in bulk in some cases. So, it’s clear that people need protection from these insurers.

    Of note, the Affordable Care Act legislation gives federal regulators authority to force insurers to turn over health plan denial information. But, more than ten years later the federal government has not collected helpful information.

    Fields reports that only two states collect some health insurer denial rates for public scrutiny. Unfortunately, they don’t collect data on most health plans.

    As Karen Pollitz, a researcher at Kaiser Family Foundation reports, “This is life and death for people: If your insurance won’t cover the care you need, you could die.” “It’s all knowable. It’s known to the insurers, but it is not known to us.. . . The insurers are not wanting to disclose this information and push back when asked for it. They claim it imposes burdens that “outweigh the benefits for consumers.”

  • Would standardizing Medicare Advantage plans protect people from making a bad choice?

    Would standardizing Medicare Advantage plans protect people from making a bad choice?

    The Medicare Payment Advisory Commission, “MedPAC,” in its June 2023 report to Congress, makes the compelling case that the government should standardize Medicare Advantage plans. The MedPAC report underscores how difficult it is for people to choose among these health plans offered by corporate health insurers. But, standardization alone will not allow people to make a meaningful choice or to protect themselves against corporate health insurers that are bad actors.

    MedPAC does not explain that the Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees Medicare, either does not have, or withholds, information about Medicare Advantage plans that people need in order to make an informed choice. MedPAC does not make the case that more information must be provided to people choosing a Medicare option. Without additional information on plan delay and denial rates, for example, it’s hard to imagine that people could make a meaningful choice.

    People enrolling in a Medicare Advantage plan today take a risk that they will end up in a plan that inappropriately delays and denies them the care they need, potentially endangering their health and well-being. According to the HHS Office of the Inspector General (OIG), some Medicare Advantage plans engage in widespread and persistent inappropriate delays and denials of care and coverage but CMS does not name these plans. Rather CMS’ star-rating system misleads people into believing that they will get the care they need in a Medicare Advantage plan with a four or five-star rating, even though those plans might be engaged in widespread inappropriate delays and denials of care.

    Right now, it is impossible for people to compare their Medicare Advantage options; they have 41 of them on average. Even the smartest people out there and the people most knowledgeable about Medicare Advantage can’t compare these plans in a meaningful way. People with cognitive impairments, low health literacy levels, or who speak English as a second language are at a total loss.

    Medicare Compare is the government tool designed to help people choose among Medicare Advantage plans. But, Medicare Compare doesn’t let you know which plans have the highest denial and delay rates, the highest mortality rates, the poorest provider networks and other telling quality measures. The most you know is whether a plan has a four or-five star rating, and the government gives out high ratings regardless of delay and denial and mortality rates.

    CMS needs to standardize benefits in Medicare Advantage plans and limit the choices available to people. Too much choice is confusing and unhelpful. CMS also needs to disclose in an easily accessible form information about the plans that are violating their contractual obligations and putting their enrollees’ health at risk, which CMS has so far failed to do.

    With the plans in the State Health Exchanges, CMS  offers four options, bronze, silver, gold and platinum. For each metal type, it standardizes the plan’s deductible, out-of-pocket limit, and cost sharing amount for most major service categories, including prescription drugs.

    Here’s more from Just Care:

  • If you’re making a Medicare choice, don’t trust the insurance agent

    If you’re making a Medicare choice, don’t trust the insurance agent

    One thing I know from experience: Don’t trust the insurance agentIf an insurance agent who is helping you decide what Medicare choices to make. It is more than possible that the agent is directing you to the Medicare choices that are the most financially lucrative for the agent.  The Commonwealth Fund reports on another issue: Agents generally will not tell you about all your Medicare choices. They might not even tell you about your choice of traditional Medicare. It’s a big problem.

    If you’re deciding between traditional Medicare and Medicare Advantage, read this. If you’re deciding among Medicare Advantage plans you should know that it’s virtually impossible to know which plan to choose. So it’s not at all clear that the limited choice the agent offers is an issue. The issue is which plan will give you the care you need at the best price, when you need it. And, no one can tell you that.

    As the Princeton health economist Uwe Reinhardt once said: To choose a plan, pick two diseases you might have next year, then find the doctors you would want to see to treat you for those conditions, then find the Medicare Advantage plan that covers those doctors. If you can find one, pick two new diseases and run through the exercise again.

    You need health insurance that protects you from unpredictable, unforeseeable health events. Unlike Medicare Advantage, traditional Medicare offers you that protection. It allows you to know that you can see virtually any doctor and use any hospital and your care will be covered. Your insurance agent is not going to be able to tell you that you will be able to see the doctors you want to see for every condition you might develop in any Medicare Advantage plan.

    If you’re making Medicare choices, you first need to think about your needs. Do you spend time in different areas of the country? Do you want to be able to see specialists or use certain hospitals? Do you have any health conditions? Do you take any prescription drugs and, if so, what will your copays be in different Medicare drug plans? Are you prepared to spend money on a Medicare supplemental insurance policy to fill gaps in traditional Medicare? Can you afford to pay out of pocket as much as $7,550 a year for in-network care alone if you enroll in a Medicare Advantage plan?

    The best independent help you can get with these questions is through a State Health Insurance assistance Program or SHIP. SHIPs provide free counseling from impartial people. They do not make money from steering you in one direction or another.

    The Commonwealth Fund recommends that CMS should make it easier for people to use “high-quality” agents and more money should go to SHIPs to provide people with independent guidance. Really? There’s no way to know whether your insurance agent is steering you towards a plan that will meet your needs.

    Much of the available information about Medicare Advantage plans is unhelpful. What people need are good meaningful choices–wide choice of providers without high out-of-pocket costs and other hurdles to getting care. Rather, The Commonwealth Fund suggests some kind of rating of agents that people can access; it also buys into the notion that the Medicare star-ratings are worth paying attention to when even MedPAC–the Medicare Payment Advisory Commission–says they are misleading.

    Here’s more from Just Care:

  • The deadly consequences of out-of-pocket drug costs

    The deadly consequences of out-of-pocket drug costs

    A new paper in NBER looks at the deadly consequences of out-of-pocket costs in the Medicare Part D prescription drug program. As you might expect, deductibles and copays keep people from filling their prescriptions. What you might not expect is that when costs rise on one prescription, people sometimes stop filling all of their prescriptions.

    Most people have little ability to rank order the value of their different prescriptions or to prioritize one prescription over another when they cannot afford them all. So, instead, they make random decisions about which ones to stop taking or decide to stop taking all of them. In short, while cost-sharing might reduce overuse of medicines, it also can lead to poor health outcomes and premature deaths.

    The researchers found that a $10.40 increase in a drug’s cost leads more than one in five people to stop filling their prescriptions altogether. It also increases the likelihood of people dying.

    When out-of-pocket costs rise, people stop taking statins and antihypertensives which can extend their lives significantly. And, people who are most at risk for a heart attack or stroke are likely to reduce their use of these drugs even more than people who are at lower risk. Socioeconomic status apparently has little bearing on people’s behavior.

    Most interesting and disturbing, the researchers find that, when drug prices increase, nearly one in five additional people opt not to fill any prescriptions. This reaction apparently holds whether they take one additional medicine or multiple additional medicines. Moreover, the risks of not taking medicines apparently have no bearing on people’s behavior.

    The researchers only looked at the effects of drug costs on patient mortality not on morbidity. They conclude that “patient cost-sharing introduces large and deadly distortions into the cost-benefit calculus. Payers should evaluate the merits of these policies in light of their impact on health, not just on health care costs.”

    If we value people’s lives and well-being, it’s time to do away with rationing care based on ability to pay. It’s time for Medicare for all.

    Here’s more from Just Care:

     

  • The wrong choice of Medicare Advantage plan could kill you

    The wrong choice of Medicare Advantage plan could kill you

    Older adults and people with disabilities have the choice of private health plans that offer Medicare benefits, sometimes called Medicare Advantage plans. Through an analysis of mortality rates at different Medicare Advantage plans, Jason Abaluck, Associate Professor of Economics, Yale University and colleagues at Brown University, University of Chicago and Northwestern University, found that the wrong choice of Medicare Advantage plan could kill you. The government would save thousands of lives if it terminated contracts with Medicare Advantage plans that have high mortality rates.

    After studying mortality rates in hundreds of Medicare Advantage plans with 15 million enrollees over five years, the researchers determined that people who choose the wrong Medicare Advantage plan have a much higher risk of dying. Put differently, your choice of health insurer affects how long you will live, along with other health outcomes.

    The researchers suggest that giving people the ability to choose between a plan that has their primary care doctor in network and one that saves them money is crazy. And, who knows which of these plans will prolong people’s lives and which will shorten them?

    They recognize that people cannot make good choices. They further recognize that the private health insurance market is broken. The Medicare Advantage plans have very little reason to put money towards keeping people healthier. In fact, some have mortality rates as high as eight percent–one in twelve of their members die each year; others have mortality rates of two percent.

    The researchers looked specifically at what happened to people’s mortality rates when they switched out of one Medicare Advantage plan and into a different Medicare Advantage plan. They found that a Medicare Advantage plan’s mortality rate had a direct effect on whether a person lived or died.

    To be clear, people have no clue what the mortality rate is for a given Medicare Advantage plan. That data is not publicly reported. And, star-ratings of Medicare Advantage plans are of no help.

    The researchers say that Medicare Advantage plans with higher premiums and better drug coverage tend to have better health outcomes. But, these two factors alone will not tell you whether you have a better chance of survival in a particular Medicare Advantage plan.

    What’s the solution? The researchers recommend that the government terminate contracts with Medicare Advantage plans that have the highest mortality rates. By so doing, the government could save around 10,000 lives a year. The better solution: Terminate all Medicare Advantage plans, eliminate out-of-pocket costs in traditional Medicare and move everyone into traditional Medicare or, better still, Medicare for All.

    Here’s more from Just Care:

  • Is it valuable to have health plan choice?

    Is it valuable to have health plan choice?

    Is choice of health plans what any American wants, asks Austin Frakt in a New York Times piece. Or do people simply want affordable choice of doctors and hospitals?

    Why would anyone want choice of health plans might be a better question. The principal reason people need choice today is financial–to be able to afford their care. But, what everyone should want is the knowledge that they can see the doctors they want to see when they want to see them, without worry about the cost. And no private health insurance plan offers them that choice.

    Put differently, it is valuable to have a health plan that delivers you the care you want at a price you can afford each and every time you need care, no matter what care you need or where you need it. If no health plan offers you that choice, what does choice give you?

    Take Medicare Advantage, private health insurance plans that offer Medicare benefits. People with Medicare have the choice of many Medicare Advantage plans. But, none offer them an open network of doctors at low or no out-of-pocket cost. In fact, people’s costs are not even predictable. Some Medicare Advantage plans deny care inappropriately and often. Who wants these choices?

    Many people sign up for Medicare Advantage plans because they do not understand what they might be giving up when they do–access to the care they need when they need it at a price they can afford. Or, they are willing to gamble that they will not need a lot of care so that they can save money. Traditional Medicare gives people the choice of almost any doctor anywhere in the country. But, it has no out-of-pocket cap. Unless you have Medicaid or retiree coverage, you must buy supplemental coverage in order to protect yourself from high out-of-pocket costs if you need care. And, supplemental coverage is pricey.

    Frakt notes that when you are choosing among private health plans, each with their own cost structure and restricted network of health care providers, it is easy to make a mistake. You can pick a plan that ends up keeping you from seeing the doctors you want to see and charging you more for your care than you ever would have imagined. People do not want to be gambling in that way if they do not need to.

    Frakt makes the wrong point. There is no way to avoid making mistakes when choosing a health plan, so long as Congress allows private health plans to offer people poor health plan choices. And, it allows health plans to keep people from knowing the ways they restrict care until they need care.

    For people to choose a health plan that meets their needs, Congress would have to determine people’s provider networks, coverage rules, and out-of-pocket costs. Congress would need to protect Americans from insurers that would otherwise not cover the care they need. Congress does not do that today, nor do the states.

    Frakt suggests that with some assistance, people could understand their health plan choices. That’s a myth. No amount of assistance will ensure people make a good health plan choice; that’s only possible if there are good choices. But, for-profit private health insurers have a disincentive to offer people good health plan choices, since giving people with costly conditions the care they need at a price they can afford would eat into private health insurer profits.

    Frakt does recognize that choice of health insurance brings with it poor health plan choices and unaffordable choices. He just doesn’t recognize that there is no way to know whether there is a good health plan choice.

    Like traditional Medicare, Medicare for All gives people the freedom to know that they will be guaranteed affordable health care coverage and be able to see the doctors they want to see. Everyone would have a good health plan choice.

    Here’s more from Just Care: