Older adults in Baltimore unexpectedly dropped from private Medicare plan offered by Johns Hopkins [Baltimore Sun]

Richard Messick and his husband moved from their health insurance into what’s known as a Medicare Advantage plan for older adults five years ago that met crucial needs including keeping their doctors.

But because they live on the Baltimore City side of the border with Baltimore County they will be dropped from the plan in the new year, thrusting them into the market for a new Medicare plan that they expect will cost more and satisfy their needs less.

Hopkins Health Advantage Inc., a Maryland health insurer affiliated with Johns Hopkins Medicine, is dropping all its customers in the city, as well as Calvert County, in what Messick can’t help but feel is a form of “redlining,” a discriminatory practice based on where people live.

The Hopkins Medicare Advantage plan will continue to be offered in 10 other Maryland counties.

“I consider myself a Baltimore enthusiast and it bothers me when my city gets the short end of the stick,” Messick said.

The Hopkins insurance company says it’s a cost issue. And the insurer isn’t alone in dropping — or never entering — the city or other parts of the state from its Medicare Advantage plans at a time when such plans are growing in popularity in almost every other state.

The Hopkins plans will cut about 5,000 people from their rolls in 2022 in Baltimore City and Calvert County, the insurer said. But in recent years state records show several other insurers have dropped more beneficiaries, particularly in rural areas.

MedStar Medicare Advantages plans left the market entirely, affecting 12,000 people; Cigna reduced service, cutting 12,000 people; and the University of Maryland Health Plan eliminated its Medicare Advantage plans, affecting about 11,000 people.

Maryland now has the nation’s third-lowest enrollment in Advantage plans, behind Wyoming and Alaska, with fewer than 13% of Medicare enrollees in those plans compared with about 41% for the country as a whole, according to an analysis by the Kaiser Family Foundation. There are close to a million older adults in the state.

Advantage plans are operated by private insurers who manage the care offered by the federal health insurance for older adults. For some additional cost, they typically offer expanded benefits such as dental and vision coverage, or gym memberships and also allow people to roll into all-in-one plans when they turn 65 from similar employer-based insurance.

Those in traditional fee-for-service Medicare plans often buy supplemental coverage known as medigap policies to cover portions of the medical bills that are not included.

Susan Goodlaxson rolled into a Hopkins advantage plan in the city earlier this year when her husband retired. The move ensured she could keep the trusted Hopkins doctors who treated her years ago for a brain tumor.

She was counting on remaining in the plan now that she has new doctors treating her for breast cancer.

She was shocked to find out she couldn’t.

“I got up Oct. 4 in the morning preparing to meet my breast cancer surgeon, and I opened my mail and a letter said my insurance was being canceled,” Goodlaxson said. “I had a brain tumor so breast cancer maybe didn’t frighten me as much, but when I opened that insurance envelope I cried.”

She understands such moves aren’t limited to the Hopkins insurance company but called the optics especially bad given that the top hospital and university of the same name call the city home.

“It’s a bad visual,” she said. “It has Hopkins in its name.”

It’s also counter to national trends, as Advantage plans are growing in other states. Officials and observers say there is more than one reason Maryland has bucked the trajectory, but Hopkins and other insurers say the main culprit is the state’s unique hospital payment model. Experts largely agree.

The goal of the model, under an agreement with federal regulators, is keeping health care spending below the national average by regulating hospital rates. That doesn’t allow insurers to negotiate payments, limiting the extra benefits they can offer and still cover spending, especially in some high-cost areas.

“This impacts the plan’s ability to generate an effective bid to CMS [the federal Centers for Medicare and Medicaid Services] and include enhanced benefits that attract Medicare beneficiaries,” according to a statement from the Maryland Health Services Cost Review Commission, which sets the hospital rates.

Hopkins Advantage said in a statement that the state’s payment model, while generally successful in reducing costs, has the “unintended side effect” that federal funding for Maryland advantage plans is 5% to 10% lower than the rest of the country.

“This underfunding is exacerbated in some regions where health risk is higher, which has caused several Maryland Medicare Advantage plans to leave the state entirely in recent years and Advantage MD to reduce its footprint,” the Hopkins statement said. “Maryland’s regulators have worked diligently and collaboratively to solve this issue but there is not yet a solution in place.”

Hopkins Advantage said it informed beneficiaries in the city and Calvert County that they can select traditional Medicare or another Advantage plan. If they don’t choose, they will be placed in traditional Medicare.

The state health commission is working on a way to substantially increase payments to entice insurers to offer more plans as early as 2022. The increase would mean a slim cut to other insurers for other insurance plans they offer and requires approval from federal regulators.

Insurers supported the move in letters to the commission. That included Hopkins (with 21,000 total Advantage beneficiaries) and Kaiser Permanente (with 46,000 beneficiaries).

Jonathan Weiner, a Johns Hopkins University professor of health policy and management, said the state’s rate-setting system is surely a factor. He said it and the Medicare Advantage plans have “suboptimal synergies.”

Advantage plans achieve savings, he explained, by keeping people out of the hospital and repurposing (including pocketing) savings, and they find cheaper ways to give hospital care, by negotiating and finding alternatives to hospitalizing patients.

“Especially the latter is tough to do here,” Weiner said.

Even if the plans achieve savings, he said, they have to pay the set rate to a hospital for services.

In addition, in Maryland some of the Advantage plans are also providers like Hopkins, “and these organizations have to balance wearing both their insurance and provider ‘hats,’” he said. “And in Maryland that is an especially challenging balancing act.”

People like Messick say Maryland consumers ought to be able to enroll in plans commonly offered elsewhere in Maryland and across the country.

“My husband and I enrolled in this particular plan because it gave us the coverage we wanted at a good price and we could stay with our Hopkins providers,” he said. “It was also attractive that [Greater Baltimore Medical Center] providers were part of the network as we live close to GBMC’s main campus.”

Now he’s beginning the process of evaluating other Medicare plans.

That could be challenging. A recent Kaiser Family Foundation report found that more than 70% of Medicare enrollees do not regularly compare plans and the percentage grew with age. Some stayed put because they were satisfied, but many more found the process difficult, the report found.

Further, when it comes to Advantage plans, the benefits are not always obvious.

A recent analysis from the Commonwealth Fund found enrollees in Advantage plans and traditional Medicare had comparable health care experiences, though Advantage plans offered more coordinated care.

They were more likely to have a treatment plan, have someone review their prescriptions and receive responses to medical concerns more quickly. Otherwise, the report found enrollees had similar demographics and comparable levels of chronic illness and wait times to see doctors.

Weiner said other scientific evidence shows Advantage plans offer higher levels of prevention and care coordination, so adding incentives to grow the plans “would seem to be reasonable.” But he added it’s not clear whether such effects would apply equally in Maryland, so understanding the environment here is essential.

Tricia Neuman, a Medicare expert at Kaiser, noted that Maryland enrollees still have choices. There are several other major insurers offering Advantage plans in Baltimore next year, according to the Medicare website, including Cigna, UnitedHealthcare and Kaiser Permanente.

“The good news is that seniors who were enrolled can switch to traditional Medicare and have access to virtually all doctors and hospitals or choose among several other Medicare Advantage plans for 2022,” Neuman said. “The bad news is that the change could disrupt the continuity of their care, if it means having to change doctors and other providers.”