Medicare ‘Disadvantage’
To the editor:
In a recent letter to the editor titled “Broken Health Care Hurts Rural Hospitals,” Don Carpenter’s title was right on track. But I would like to offer some different ideas on why US health care is broken. The US spends far more than other wealthy countries (OWC) per capita on health care, and yet has much worse outcomes than the average of the OWC. They average $6,414/person while the US averages $12,555/person, according to the Peterson Center on Healthcare. In 2020 the US spent 18.8% of the GDP on healthcare, while the OWCs spent 11-12% of their GDP. And the US spent $925/person on administrative costs, four times the amount of the OWCs. Meanwhile, the US spent $924/ person on long-term healthcare, while the OWCs spent $1,182/ person. With all this expenditure, we should have fantastic health outcomes. But instead, we are in the lower 1/3 in outcomes for life expectancy at birth, infant mortality, unmanaged diabetes, and safety at childbirth and are only average in outcomes for unmanaged asthma and heart attack mortality.
In my opinion, and in the opinion of many other experts in this field, the problem is the complexity of our current system. I know this well, as I have been in health care policy decisions in my previous roles as president of the Texas Academy of Family Physicians, on the legislative committees of the TAFP and the Texas Medical Association, and on the American Academy of Family Physicians Rural Health committee. This complexity and additional costs this puts into health care is what is driving the disparity in our costs and in our outcomes. In regards to Medicare and rural hospitals, MEDICARE IS NOT THE PROBLEM. It is important for each of Medicare-eligible individual to realize that if they opt for a “Medicare Advantage” plan (called by many of us a “Medicare Disadvantage” plan) that they no longer have Medicare, but instead have an insurance plan through a corporate entity and are subject to different rules than with Medicare.
So, why do some of us call them Medicare Disadvantage plans? Though they may offer some perks that are enticing, many individuals never utilize those perks. These plans require prior authorization for many procedures and tests, requiring physicians and hospitals to expend time and staff effort to get them approved. For a Medicare patient, I can order an MRI, for example, and if there is an opening in the radiology schedule, can have it done that afternoon. For an Advantage patient, I have to get authorization, and if it is approved, it takes days to weeks to get it done. If I want to refer you to a specialist, I may not be able to send you to someone I know and have seen the quality of their care, but rather have to pick from a list that the insurance company provides. Medicare is accepted all over the US, but Advantage plans have geographic boundaries, so that if you have a health issue while traveling, you may be out of network, and have significantly lower coverage for any medical visits or procedures you may need. Heck, if you live in Fayette County and have certain Advantage plans, you will be out of network if you come to Columbus Community Hospital 26 miles away.
And finally, in regards to hospital financing, Advantage plans are truly a disadvantage for all hospitals. Even in the big city, some hospital systems are no longer accepting patients of certain plans because their reimbursements don’t cover their costs. At one time, Medicare was one of the lowest paying insurance payors, but today, Advantage plans are frequently offering less than Medicare rates to hospitals, and frequently deny inpatient payments for some hospital stays that we feel are legitimate. In addition, Medicare has additional payments to hospitals, especially rural hospitals, based on things such as charity care, educational activities and others, that allow the hospital to remain viable and continue to be available for quality care at home.
So I encourage you, Mr. Carpenter, and all of you Mediare eligible individuals, to not be persuaded by the slick ads and phone calls you will get luring you to an Advantage plan when it comes time to enroll this fall. The availability of your local physicians, and your local hospital depends on your choice. Make sure you chose Medicare, and not a corporate insurance plan!
Thomas E, Mueller, M.D. Fayetteville