Sick patients flee from Medicare Advantage to Medicare

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Medicare Advantage insurance companies have been criticized by the CMS (Centers for Medicare Services) for denying needed health care to sick patients. On appeal, 80% of these denials are reversed – but it’s stressful and time-consuming to appeal so few denied patients do.

But the word is getting out. If you are sick and really need insurance, choose government-run Medicare over Medicare Advantage.

https://www.wsj.com/health/healthcare/medicare-private-plans-insurers-389af1a0?mod=hp_lead_pos7

The Sickest Patients Are Fleeing Private Medicare Plans—Costing Taxpayers Billions

Medicare Advantage patients in the last year of life were far more likely to switch to traditional Medicare, shifting costs from insurers

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People in the final year of their lives left Medicare Advantage for traditional Medicare at double the rate of other enrollees from 2016 to 2022, the Journal’s analysis found. Those private-plan dropouts—300,075 during that time span—often had long hospital and nursing-home stays after they left, running up large bills that taxpayers, not their former insurers, had to pay.

They cost the federal government an average of $218 a day during that period. That is more than seven times the cost of a typical Medicare recipient, and about twice the cost of other recipients in the last year of their lives. The Journal’s analysis excluded hospice expenses, which traditional Medicare typically covers for all patients.

Medicare Advantage insurers collectively avoided $10 billion in medical costs incurred by the dropouts during that period, the analysis found. If those beneficiaries had stayed in their plans, the government would have paid the insurers about $3.5 billion in premiums, meaning the companies netted more than $6 billion in savings during that period… [end quote]

Some METARs may have Medicare Advantage because the cost is lower and it covers many maintenance costs that Medicare doesn’t cover. But beware! Medicare Advantage is likely to deny claims just when you need coverage the most.

And be sure to get a good Medigap plan (we have Plan G) if you get Medicare to cover the 20% that Medicare doesn’t cover.

Medical costs can be astronomical. My surgery is in a week from today. I will update on costs as they work their way through the system. If all goes well, my out-of-pocket cost will be zero because I have already satisfied my deductible.

Wendy

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It is not costing the taxpayers a cent. This is an obligation that was created long ago and in larger part funded by those in the pool.

The MAs are destroying this country for their wallets. Let’s stop pretending capitalism is innocent.

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BTW your source is planting a hit piece. The WSJ is using its readers.

Think about that. The story leverages people against government expenditures when the private sector makes an enemy of itself.

MA never should have been legalized. The story is just playing with the readers.

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I’m a healthy, fit 66 year old female with no prescriptions. I live in a health care desert. Many medical procedures would require travel 250-300 miles to Santa Rosa or San Francisco, CA. Who knows which network the provider would be in. I chose traditional Medicare since I can afford it. When I was on ACA, I experienced pre-approval nonsense. Not going through that again.

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Medicare Advantage does invest in keeping you healthy. Lots of extras like dental, glasses, hearing aids, gym membership included in premium. Many plans with no extra payment above basic Medicare. Most with no deductibles.

Most are PPO or HMO plans requiring in network for best coverage. Some plans are very well accepted with most doctors and hospitals in network. I have AARP United Health Care HMO Medicare Advantage. So far no complaints.

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" I have AARP United Health Care HMO Medicare Advantage. So far no complaints."

The operative words are “so far.” Hopefully you won’t get the kind of serious problem that would cause denial.

Wendy

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Aetna offered that this year with their best plan. Plus more. It nearly put them out of business. It is unaffordable. They dumped the plan.

Now they and United off more barebone plans. That is why people are reverting to Medicare.

We can expect cuts in MA, Medicare, and Medicaid on tap. More of a reason for people to go back to Medicare. Some security in what will happen.

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Indeed I’m saving $2k/yr with Medicare Advantage. In 30 yrs that’s $60K. So if I get stuck with extra costs later, the first $60K is merely catching up.

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Each year Medicare sends each of us a paperback book listing all the plans in your area and their prices. Its easy to see what your choices are. And what charges there are for office visits etc. Learning about the extras maybe takes a phone call but clearly not difficult.

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But you have to watch out for the “medicare advisors” that are really just salesmen for several advantage plans, and usually not the best.

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The only problem is that as Private Equity and Big Medicine buy up more Doctor’s practices, they’re forcing you to take Medicare Advantage if you want access to a Primary Care doctor. They can make more money by getting the lump sum from Medicare, and then denying you health care.

My Primary Care doctor was bought out 2 months ago and the new Big Medicine shop wants everyone to be on Medicare Advantage for Jan 1st. Sometimes they have to grandfather-in folks on regular Medicare to get regulatory approval for the buy out, but it’s not guaranteed.

Oh well, I’m fine with going to urgent care if a need a referral to a specialist or a refill on a prescription, just as long as I’m not in Medicare Advantage.

intercst

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Well, if you were banking on that $60k as a catch up, wouldn’t that require you to have taken out an MA plan at age 65, live until age 95, making claims that’re fully reimbursed and with no denials/delays to treatment that actually shorten that theoretical lifespan or make it so miserable that you want it shortened? That sounds a bit like an over optimistic risk calculation even in the face of rude good health

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That is not true.

20 at a whack

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Actually, it IS a reality in many parts. Corporate medicine is rolling along like a juggernaut in these parts. My primary care practice is still a hold out for independent care but there are very few left.

The two primary care practices that I’m aware have been swallowed up by a corporate entity (my daughter’s PCPs since her move to Colorado 11 years ago) and have transitioned to this business model on her watch…and moved to basically a PA run practice each time. Both also had notices posted advising that as of a given date, they would be participating in MA plans only. I know this because both times it happened my daughter asked for an explanation of why a business owner would do that …to which the obvious answer is that none of the folk working there are the business owners any longer and is why the service has deteriorated the way it has.

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The bills haven’t started rolling in for my current heart problem, but I can tell you that the bill for my breast cancer surgery – ONE NIGHT in the hospital, not including the testing before – was over $150,000.

My current problem will include testing (including transesophageal ultrasound, CT scan and angiogram) plus open-heart surgery (including synthetic heart valve and aorta) with at least one day in the ICU plus perhaps 5 days in a “telemetry” room with continuous heart monitoring plus who knows how many additional tests. If this doesn’t add up to at least half a million dollars I will be the most surprised gal in the room. Given my level of general good health I don’t expect expensive add-ons like dialysis, treatment of infections, etc. (Kinehora to avert the evil eye!)

Nowadays, $60,000 is just a down-payment for any serious health problem. The cost is astronomical.

Wendy

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I had heard Medicare can be rejected but I had not expected the MA insurance owned offices to be leading the charge to reject Medicare.

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Actually Medicare at age 65 and living to 95 (or more) is my life plan. I began with Medicare Supplemental from Anthem and Part D from Humana. That is the basis of my $2k savings with Advantage. That included $400 drug deductible. And premiums abt $150/mo in addition to basic Medicare.

As to PCP, mine from 2006 just retired. His firm gave me a brand new beginner to train. So far so good. Just met her this week.

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I hope the coverage there when you need it.

It is not well enough understood that Medicare Advantage plans, despite the hype about extra services and even no-premium plans, are second-tier coverage. Medicare has bifurcated into Traditional Medicare, which provides generally pretty good coverage, albeit at a bit of a cost, and Medicare Advantage, which among other things has skimpier networks and a lot of gatekeeping to restrict the provision of care. The Wall Street Journal describes how adverse selection works, with patients who had enjoyed cheaper/lower service Medicare Advantage plans switching to Traditional Medicare as they get sicker.

As recipients get sicker, though, they may have more difficulty accessing Medicare Advantage services than people with traditional Medicare. This is the result of the insurers actively managing the care, including requiring patients to get approval for certain services, and also limiting which hospitals and doctors patients can use.

It does worsen as people age.

The Wall Street Journal found more people in the final year of their lives are leaving Medicare Advantage for traditional Medicare at double the rate of other enrollees. This was occurring from 2016 to 2022. Those private-plan dropouts numbering ~300,075 during the 2016 to 2022 time span often had long hospital and nursing-home stays after they left. The result of their going back to Traditional Medicare being large bills paid from Medicare’s Hospital Insurance (2.9% split between workers and business) fund.

In one WSJ example of end-of-life healthcare, the total cost would have been $ .9 billion if the patient was in Traditional Medicare as compared to $2.4 billion for a person who switched back to Traditional Medicare from Medicare Advantage. The Wall Street Journal provides a chart (see below) detailing the cost of switching back using various providers of MA plans as compared to Traditional Medicare.

Medicare Advantage insurers collectively avoided $10 billion in medical costs incurred by the dropouts during that period, the analysis found. If those beneficiaries had stayed in their plans, the government would have paid the insurers about $3.5 billion in premiums, meaning the companies netted more than $6 billion in savings during that period.
Quite the business model when corporate Insurers can dump their most costly insureds onto the Traditional Medicare plan.

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Great to read you can switch back to Medicare Supplemental if you need to.

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I’m sure that is subject to underwriting by medigap Insurers. Methinks not not all applicants are accepted.

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