JustCare

Tag: Dr. Oz

  • Medicare Advantage costs and prior authorization rules impede access to care

    Medicare Advantage costs and prior authorization rules impede access to care

    Medicare Advantage costs and prior authorization rules continue to impede access to care. Anyone enrolled in a Medicare Advantage plan–Medicare coverage administered by a corporate health insurer–should be concerned about whether they will be able to get and afford the care they need if they get sick. Traditional Medicare provides coverage for care from almost any physician or hospital in the US without the need for prior authorization.

    Jakob Emerson reports for Beckers Payer that typical deductibles for Medicare Advantage plans are now more than twice what they were in 2024. It’s fair to assume that they will continue to rise, given the Trump administration’s full court press on government spending. You’ll be fine in Medicare Advantage if you’re healthy, but you’ll likely be far better off in traditional Medicare if you want to ensure you’ll be able to afford and receive the care you need when you get sick.

    Average Medicare Advantage deductibles were about $132 in 2024 and are now $315, according to an eHealth survey. That’s a 139 percent increase. Monthly premiums average just $5 a month this year, down from $9 in 2024. And, total out-of-pocket costs for covered in-network services can be as high as $9,350 this year, depending upon the Medicare Advantage plan.

    Average Medicare Part D prescription drug coverage premiums are also up, from $29 to $36, about 25 percent.

    Meanwhile, prior authorization rules remain another obstacle to care for Medicare Advantage enrollees, particularly those who need costly and complex care. Rylee Wilson reports for Beckers Payer that some states are looking into regulating insurers’ use of prior authorization. They are especially focused on insurers’ use of artificial intelligence or AI to determine whether a procedure should be covered and want a physician to oversee those decisions. (Could  that simply mean a physician rubber-stamping them?)

    Patients are currently suing UnitedHealth and Humana for using AI to deny rehab care in Medicare Advantage inappropriately. UnitedHealth spokespeople argue that they do not use AI exclusively to make coverage decisions. They might not, though having a provider oversee these decisions with financial and other incentives to approve them is no better than using AI exclusively.

    Last year, the Centers for Medicare and Medicaid Services, CMS, which oversees Medicare, issued guidance on the use of AI in Medicare Advantage. CMS did not ban the use of AI or even restrict it. It simply said that the AI algorithm must comply with Medicare’s coverage requirements. Good luck enforcing that rule.

    Dr. Mehmet Oz, who will head of CMS, once confirmed, believes in AI as a tool for expediting prior authorization decisions–seemingly, even though they can speed up inappropriate denials. However, Oz says that insurers should not use AI for more than 1,000 procedures.“I would argue that to use AI wisely, we would make a decision which is we’re only going to pre-authorize 1,000 procedures,” he said at a recent Senate hearing. Where he pulled the 1,000 number from is anyone’s guess.

    Here’s more from Just Care:

  • Republicans look to end Medicare Advantage overpayments

    Republicans look to end Medicare Advantage overpayments

    More members of Congress on both sides of the aisle are looking at ways to end massive overpayments to Medicare Advantage insurers as a means of reducing federal spending, reports Peter Sullivan for Axios. Ending these overpayments should not affect people’s Medicare benefits, it would simply put spending in Medicare Advantage for each enrollee on a par with spending in Traditional Medicare. In sharp contrast, cutting Medicaid benefits would likely cause tens of millions of Americans to become uninsured or underinsured.

  • Don’t trust social media for wellness advice

    Don’t trust social media for wellness advice

    You likely see dozens of clips each day providing wellness advice. Unfortunately, a lot of what you see on social media and TV should not be trusted. What should you do? Jude Joffe Block reports for NPR on what’s happening on social media. Reed Abelson and Susanne Craig report for the New York Times on the misleading information that Dr. Oz promotes, while benefiting financially.

    Dr. Oz has promoted Medicare Advantage plans endlessly, without warning people that they could struggle getting the care they need in a Medicare Advantage plan. Insurers offering Medicare Advantage delay and deny care inappropriately and routinely, particularly costly care. They have a powerful financial incentive to do so. Every treatment they delay or deny helps maximize their profits. Like the insurers, Dr. Oz profits from promoting Medicare Advantage.

    Dr. Oz also has profited to the tune of tens of millions of dollars from selling supplements, even when there is little or no scientific evidence to show any benefits from the supplements he promotes and, in some cases, people can be harmed.

    Some people are trying to fight online misinformation from wellness influencers with accurate information. That’s tough. You want to be sure that whatever wellness advice you’re taking is based on science and not hokum. You can save money by not consuming products that are of no value or, worse still, harmful to your health.

    Whose wellness advice should you take? You probably should not listen to anyone who makes money from providing wellness advice. Anyone profiting from providing advice has a conflict of interest, including Robert F. Kennedy, Jr., the newly confirmed Secretary of Health and Human Services.

    For example, if you look at the scientific evidence, you should be getting a vaccines for Covid and a range of other conditions, even though RFK Jr. likely disagrees. Medicare covers a range of vaccines. And, for most, you have no out-of-pocket costs so long as you get them from a Medicare participating provider.

    Here’s more from Just Care:

  • Is Mehmet Oz fit to run Medicare agency?

    Is Mehmet Oz fit to run Medicare agency?

    Last month, Senator Elizabeth Warren, along with six other Democratic Senators, sent a letter to Dr. Mehmet Oz, whom President-elect Donald Trump has named as Administrator-Designate, Centers for Medicare & Medicaid Services (CMS), regarding Dr. Oz’s call for the elimination of traditional Medicare and his lack of qualifications for the CMS Administrator position. If Dr. Oz becomes head of CMS will we be playing with fire?

    Dr. Oz has substantial investments in corporate health insurance companies. He has said that he wants everyone with Medicare in a Medicare Advantage plan, even though Medicare Advantage does not work for large swaths of the population. (People in rural communities who are in Medicare Advantage plans often must travel tens of miles to receive hospital care because their Medicare Advantage plans won’t pay their local hospitals appropriately. People with cancer in Medicare Advantage plans can’t see physicians at cancers centers of excellence because they are all out of network. People who travel and need care in multiple parts of the US can’t get the in-network coverage they need in Medicare Advantage. Amputees and other people needing rehab services too often can only get that care covered if they are in traditional Medicare.)

    Dr. Oz also either does not appear to appreciate or does not care that traditional Medicare is far more cost effective than Medicare Advantage. He either does not know or does not care that Medicare is overpaying corporate health insurers operating Medicare Advantage plans tens of billions of dollars each year.

    MedPAC projects that these insurers will overcharge CMS $83 billion relative to traditional Medicare in 2024 alone. To maximize profits, private insurers make their MA enrollees appear sicker than they actually are. The HHS Office of the Inspector General finds that insurers engage in constant inappropriate delays and denials of needed care and force physicians and hospitals to jump through hoops to deliver needed care. Dr. Oz does not seem to know about or ignores these abuses.

    Dr. Oz also has a financial conflict of interest. He owns more than $550,000 of stock in UnitedHealth, which is under Justice Department investigation for antitrust abuses. But, his desire to eliminate traditional Medicare would double revenue for UnitedHealth to nearly $300 billion.

    Senators Warren, Wyden, Cardin, Merkley, Durbin and Blumenthal ask Dr. Oz for answers to a series of questions by December 23, 2024:

    1. Does he continue to believe traditional Medicare should be eliminated and, if so, why?
    2. Will he commit to protecting Medicare, not privatizing it or cutting benefits?
    3. Does he understand why Medicare Advantage is highly dysfunctional and, if not, what does he think about the upcoding and widespread delays and denials of needed care?
    4. Will he sell off all investments in health insurance companies in order to ensure he has no financial conflicts of interest if he is confirmed as CMS Administrator?

    Here’s more from Just Care:

  • Supplements: John Oliver vs. Dr. Oz

    Supplements: John Oliver vs. Dr. Oz

    For decades now the dietary supplement industry has been marketing magic, and the comedian John Oliver just took the industry to task.  He also makes hay of Dr. Oz for promoting these supplements as magic pills on his TV show.  Click play to watch above.

    In brief, there is virtually no regulatory oversight of dietary supplements, including all those miracle vitamin pills you see advertised everywhere you turn.  The Food and Drug Administration (FDA) lacks the authority to regulate the industry, except when there is evidence of serious injury to Americans.  And, then, it can take a long time—many people can die and many more can become seriously ill before the FDA has the ability to take the product off the market.  Ephedra is one case in point.

    Consumer groups have lobbied to give the FDA greater oversight over the multi-billion dollar dietary supplement industry.  The industry, in turn, has lobbied Congress heavily to stay away.  Senators Harkin and Hatch, two of many members of Congress who have received substantial campaign dollars from the industry, have been its chief proponents, fending off efforts to enable FDA oversight.

    Before you spend another dime on a dietary supplement, watch this video.  And, read our Take Care posts on why you should eat oranges, leafy greens, nuts and eggs over vitamin supplements, including Vitamins B6, C and E.  Save your money!

    Here’s more from Just Care: