Medicare “Disadvantage”
It’s Medicare Open Enrollment time again, and I provide my annual warning of the major pitfalls of Medicare HMO “advantage” plans.
When our family first came to California in 1954, we joined the Kaiser HMO plan. My older adult mother, who insists on remaining on their advantage plan, will soon be 103 years old! They have done their job, although my aunt (her sister) just turned 100, so there may be a contributing genetic component to their longevity as well.
For those who don’t know, advantage plans are for profit, and some medical decision-making is based on their bottom line. Healthcare professionals in these organizations generally make good decisions, but sometimes they are overridden by administrative non-medical MBAers.
My brother and I are doctors, so we know how to navigate the system. Of course, we have been able to guide our mother to 103 years old. But many of you don’t have this background and must rely on doctors, nurses, relatives, friends, and Google to make decisions.
Medical technology is changing fast, so obtaining accurate information is sometimes difficult. New technology is sometimes under-utilized because it might not be deemed evidence-based according to the advantage plan. How does one put up a case against their Ivy League MBA administration?
Some of the “disadvantages” of being on a Medicare advantage plan are their ads and commercials are not truthful. The so-called “extras” probably don’t exist, although some of you might receive them because you are a “squeaky wheel.” But headaches, time, and phone calls usually result in zilch and out-of-pocket expenses.
Your advantage doctor’s medical decision-making can be thwarted by administrative “denial” or the need for “prior authorization,” which takes time, augmenting anxiety when you have a mass in your breast.
Maneuvering through the “denial” process is not easy.
Traveling on vacation or visiting grandkids across state lines or jurisdictions can delay care if the emergency room has to contact your plan and they are closed because of cross-country time differences. In the ER, do you need this delay?
Many of our seniors continually maintain their medical care has been “great” on the advantage plan, but they haven’t yet been stricken with a life-threatening illness. Unfortunately, as a hospice doctor, I have seen some of these organizations quickly convince patients and family members of the “advantage” of going on hospice. The MBAers know that once this happens, their HMO organization can “financially wash their hands” of those patients as they go into a new Medicare category.
The “advantage” of being on an advantage plan is its cost. It is cheaper. However, I always recommend that members of our community find an insurance agent knowledgeable in this complex field to see if they can find an affordable plan. Typically, their charge is nil or reasonable. It could save your or your loved ones’ lives!
Weighing between an “advantage” plan and original Medicare is complicated. Both have positive and negative aspects. Though, the adage “You get what you pay for” comes to mind.
Yet, there are successes—just ask my mother.
Gene Dorio, M.D.
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