Malek: Medicare dis-Advantage

The Medicare program's annual open enrollment period extends from Oct. 15 to Dec. 7. During this period, beneficiaries can buy supplemental private insurance (Medigap plans) to cover Medicare's substantial deductibles and copays. With this additional protection, beneficiaries incur virtually no out-of-pocket costs payments, can consult any hospital and doctor who has signed up with Medicare. Unfortunately, the cost of these "Medigap" plans has steadily risen, and now cost approximately $2,000 annually. This represents a financial hardship for many senior citizens.

After a series of successful lobbying blitzes beginning in the 1980s, the health insurance industry "persuaded" the U.S. Congress to create a second type of option: Medicare would make regular payments to private plans, which would then be responsible for paying the doctors and hospitals. And the insurance lobby also succeeded in getting Medicare to grossly overpay the private plans, which are now called "Medicare Advantage" (MA) plans, so that every time someone signs up for one of these plans, the Medicare trust fund currently pays approximately 25% to 30% more than Medicare would have paid out had the patient remained in traditional Medicare. These overpayments are so extravagant that these plans have enough money to:

— Keep the monthly premiums quite low.

— Offer extra benefits — eyeglasses, hearing aids and some dental care.

— Spend tens of millions on advertising and pay insurance brokers a good deal extra for MA sign-ups.

— Provide lavish dividends to investors and upper level management.

So the Medicare Advantage option works out really well for insurance companies, but what does it mean for beneficiaries who sign up for the plans? The advertising blitz typically incorporates well-paid, geriatric opinion leaders like Joe Namath to extol these plans, asserting that they cover everything in traditional Medicare and more, and for a lower price.

My mom taught me that, if something sounds too good to be true, it probably is just that. Here's the rest of the Medicare Advantage story:

— The networks: Unlike traditional Medicare, which covers care from nearly every physician and surgeon in the country, Medicare Advantage plans confine you to a limited network of physicians. This may work out if all your health problems turn out to be common ones. But if you're traveling out of area, or if your illness is serious and less common, there's a good chance that the designated network will not provide you the best treatment.

— The copays: If you buy traditional Medicare Supplemental Insurance, you're responsible for minimal out-of-pocket payments. This is not the case for Medicare Advantage. You can expect significant copays with nearly all the medical services you receive. If you use a service that generally healthy people receive — vaccines, primary care visits, or screening mammography — copays will be minimal. But when you become ill, well … that's a different story. MA plans are permitted to charge up to $8,300 annually — and considerably more if you dare to stray from the plan's network of physicians. And pharmacy costs can add many thousands more.

— The payment denials: Medicare covers all medically necessary services. In traditional Medicare, your doctor decides what's medically necessary. Who decides that if you have an MA plan? You guessed it, the plan decides — not your doctors.

This is not a mere theoretical concern. During my six years working at Springfield Hospital, MA plans were denying payment frequently and almost at random — often for entire hospitalizations. Some of these denials left me speechless. One of the largest of the MA plans denied payment for an agitated, delirious woman whose spinal tap demonstrated clear evidence of a brain infection — a brain infection.

Payment was denied when we refused to discharge an elderly patient with advanced dementia, who had fallen and broken her shoulder and hip. Her family opted for comfort care, but her MA plan would only pay if that care occurred at home. Her nearly 90-year-old husband couldn't possibly have cared for her at home. We were not paid. No leeway was granted for the situation her husband would have faced. There are no exceptions.

And if you're in an MA plan and you need rehab after a hospitalization, well, good luck with that. Over the next few years, expect to see more and more nursing homes, rehab centers and rural hospitals drop out of the Medicare Advantage program entirely.

A doctor's order for anything other than a routine test or treatment can expect a time-consuming flurry of paperwork known as "prior authorization." In this process, an MA employee sitting in a cubicle in a suburb somewhere gets to decide whether the plan will cover the plan the doctor has proposed. It doesn't matter that the individual sitting in the cubicle may have no medical training whatever, has never met your patient, and knows nothing of the issue your patient is facing.

In 2021, Medicare Advantage plans required 35 million prior authorizations. Two million were denied. This entire process imposes a great deal of stress and often materially worsens outcomes for patients whose treatment was delayed or foregone entirely. For primary care physicians, who are in short supply, this process is time-consuming and adds to their frustrations.

Last year, the federal Office of the Inspector General found that at least 13% of prior authorization denials were inappropriate and 18% of payment denials were unjustifiable.

4. Getting out of Medicare Advantage: MA plans may work well for you — until you get sick. But given the above, if you become ill, there's a good chance you'll want to exit your MA plan and return to the security of traditional Medicare. You can, but … if you want to buy a Medigap policy at that point, the Medigap insurer can decline to cover you at all, or charge you higher premiums for the rest of your life.

Eliminating the deductibles and copays in Traditional Medicare could give every single Medicare beneficiary high-quality benefits, and obviate the need for you and other beneficiaries to decide between higher premiums in traditional Medicare with a Medigap plan or putting your health care in the hands of a profiteering private insurer. Redirecting the overpayments to Medicare Advantage plans to this end could go a long way toward providing the funding to an improved Medicare. Send a letter with this message to all three members of our federal delegation.

Marvin Malek is an internist who resides in Berlin.