Insurers should look at themselves if Oregon officials dump Medicare Advantage
Insurers can sculpt much of what happens in health care. A scene from St. Charles shows how.
A woman in her 80s came into one of the hospital system's emergency departments this month. Her high blood pressure was out of control. Her heart rate was high. Her heart rhythm was abnormal. And her mental status made it difficult to treat her. She had to be physically restrained at one point, Dr.
She was admitted. The staff at St. Charles stabilized her blood pressure, her heart. Her mental status remained tricky. The staff at St. Charles looked for options where she could get the additional care she may need, perhaps at a memory care center.
After four days, her mental status became more normal. She could manage her medicines. She was able to be discharged home with her daughter.
There's nothing about that part of her care that sticks out. But her Medicare Advantage insurer denied her inpatient admission. The company said it would treat it as outpatient care, Hallet told us. The insurer basically switched the billing in a way to give the patient high copays and deductibles. Doctors and staff at St. Charles now have to go and argue with the Medicare Advantage insurer why it is not best for the patient to retrospectively deny a four-day admission.
That example is one of the reasons why St. Charles may drop participation in all Medicare Advantage plans. It's a type of Medicare insurance that can be a good deal for people in coverage and cost. It can also be a bad deal for patients and providers.
Staff at the hospital believe it is not the best way to care for patients. It can put patients in a financial vise. Medicare Advantage can mean it takes longer for the hospital to get authorization for care. It can mean patients stay longer at the hospital than is appropriate, because they can't be discharged to a place that would be a better option. Those issues don't just come up at St. Charles. It happens across the country.
"Whatever the financial component of this is, we are talking about elevating the concerns of patient safety and quality of care as well as caregiver burden to the same level of concern that insurance companies have" with their interests,
Some say the advantage part of Medicare Advantage is to insurers. Insurers love it. It is paid for by the federal government. Private insurers run it. And it is very profitable.
Volleys at health insurers are routine in the world of health care reform. Some see insurers as specters to be tamed or slain.
We would rather see consumers have the choice of Medicare Advantage. We worry consumers may struggle with any change. It also seems wrong that a hospital system can effectively banish a legal type of health insurance coverage. But Dr.
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