Yesterday, I saw a sweet and very sick Medicare patient. We are talking multiple organ disease from several different (unrelated) medical problems. And no, all her issues do not stem from smoking or overeating, so please, those of you who think that the chronically ill are not deserving of our attention or sympathy, please hold your peace. This woman has been very unlucky. But medical science is keeping her together. She is upbeat. She is proactive in her health care.

Why am I writing about her? Because, yesterday, during a routine office visit,  I found myself doing something that I have never done before---as part of her health care planning, I had a discussion with her warning her of the dangers of Medicare Advantage.

Most people who take time to familiarize themselves with the complicated (and sometimes infuriating) issue of health care in America know about the problems with so called "Medicare Advantage" plans. These privates take a flat fee and agree to pay for all health care costs for their enrollees. Since they can not turn down applicants for pre-existing conditions, they use many (sneaky) strategies to drive away sick patients in order to cut their out of pocket expenses and increase their profits. Strategies such as denial of coverage for medications, procedures, hospitalizations, specialty care etc. The patient and the doctor are forced to jump through hoop after hoop in order to get essential health care services. Patients find that they can not get the  care they need in their area. Eventually, many "ill" patients who are on a so called "Advantage" Plan will go back to traditional Medicare---meaning that "Advantage" plans do not save tax payers dollars. Instead, they allow privates to skin the cream from the top of Medicare by collecting premiums for people who are never sick while saddling the rest of us with the bills for the sickest beneficiaries.  


Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries. Disenrollees had higher risk scores and incurred higher risk-adjusted payments than beneficiaries in FFS. Their high risk scores are in contrast to the risk scores of the general MA population, most of which is enrolled in plans with average risk scores similar to or less than local FFS experience (United States Government Accountability Office, 2010). Recent studies have also shown that MA plans continue to experience favorable selection through enrollment of low-cost beneficiaries (MedPAC, 2012; Riley, 2012). These research findings suggest a pattern of selective disenrollment whereby disenrollees are sicker and more expensive than the beneficiaries who remain enrolled in MA plans. This selective disenrollment potentially increases Medicare costs through the return of high-cost beneficiaries to the FFS sector, leaving behind a healthier and lower-cost population in the capitated MA sector.
Most of the folks reading this already know the results of this study. So, why am I flogging the dead horse? Because, yesterday, for the first time, I looked at a patient and thought "If this poor woman gets suckered into signing up with an Advantage plan, she is doomed." And so, I counseled her to avoid them like the plague, the same way I would counsel her to avoid cigarettes, mosquito bites (we have West Nile in the area) and a high fat diet.

I was not riding a political horse. Politics were the last thing on my mind. I was being pro-active, the way that a primary care doctor is supposed to be. And I knew that if a so called Advantage Plan forced her to stop any of her essential medications for 2-6 weeks while she appealed denials of coverage or denied her care with a specialist or cut off her home health benefits, she would be, as they say, toast.

Medicare Advantage execs reading this, are pleased, I am sure. They want primary care doctors to do their job for them. They want us to steer our sickest patients away from them and onto traditional Medicare. Any Medicare Advantage execs reading this, please take your smug satisfaction with you and exit the area. What I am about to say is for the rest of us.

A family doctor in this country should not have to become their patient's insurance agent. She should not have to warn patients away from certain types of plans that are U.S. government approved and funded. The Medicare program should look out for its beneficiaries. But it does not. Thanks to greedy private ensurers, Medicare is currently broken. Damaged. The way that so called Managed Care plans (HMOs) of the 1990s damaged health care for many working Americans.

Remember how bad your HMO was? Well, imagine that you are twenty years older, three times sicker and even more dependent upon your medications with much less disposable income for those instances when your insurer denies you essential care. Now,  imagine that your "Advantage" plan says it will not cover your (generic) anti-angina  medication, even though you have blocked coronary arteries. What? You need that medication? You are free to switch to another medication that they do cover, but you will have to talk to your doctor first. Your doctor is out of town for a week? Well, just try not to get excited. Or, you can buy the medication out of your own pocket. What's that you say? You don't have any cash at the moment? You signed up for an Advantage plan because you are poor and you were told it had better drug coverage and would save you out of pocket expenses and make it possible for you to follow your medical regimen? Silly rabbit. Your Advantage plan is not here for you. It is here for its execs. Now, get back to traditional Medicare where you belong and let us open up a new spa for our healthy, rich seniors.

Pissed does not even begin to describe how I feel right now. I am scared. Scared for my patients. Scared every time I get a fax saying "Insurer A won't cover Mr. B's cholesterol medication". You see, Mr. B has a bad heart. And if he can't get his cholesterol medication, he may have another heart attack. And I don't want Mr. B to have another heart attack. He does not have much myocardium left. But I don't want him to get on a medication that he is allergic too or that will hurt him in other ways. And I don't want to tell him "Go buy the denied drug at Wal-Mart. It is $4 there." Because he may not have $4. And why is he even paying a Medicare premium if his "Advantage" Plan will not pay for his $4 drugs?

Originally posted to McCamy Taylor on Sun Sep 29, 2013 at 11:11 AM PDT.

Also republished by Community Spotlight.

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