Medicare Halts Release Of Much-Anticipated Data

[turbinetree]

Source: National Memo

Reprinted with permission from ProPublica.
by Charles Ornstein

In the past few years, many seniors and disabled people have eschewed traditional Medicare coverage to enroll in privately run health plans paid for by Medicare, which often come with lower out-of-pocket costs and some enhanced benefits.

These so-called Medicare Advantage plans now enroll more than a third of the 58 million beneficiaries in the Medicare program, a share that grows by the month.

But little is known about the care delivered to these people, from how many services they get to which doctors treat them to whether taxpayer money is being well-spent or misused.

The government has collected data on patients’ diagnoses and the services they receive since 2012 and began using it last year to help calculate payments to private insurers, which run the Medicare Advantage plans. But it has never made that data public.

Read more: http://www.nationalmemo.com/medicare-halts-release-much-anticipated-data/

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I think, we that are in this program want to know if the for profit are over charging................... its that simple.....

[rurallib]

1. My MIL is entering the nursing home club right now

and her Humana Plan is kind of all over the fucking place on what they cover and how much.
I bite my lip a lot.

[enough]

2. Medicare or Medicare Advantage will not cover long-term nursing home care,

only short term care for rehab after injury or hospital stay.

[Hieronymus]

8. They'll be in very bad shape when Medicaid is cut.

[rurallib]

20. Yep - and we live in a state with "filial responsibility"

which means if she can't pay the cost falls back on the kids.
Or we care for her ourselves.

Talk about a pull the plug on granny choice.
We can't afford $3500/month by any means and my wife has serious physical problems. I have a hard enough time taking care of her.

[Ligyron]

21. Yours is the kind of story that deserves to be told my the MSM.

Repeatedly.

A lot of folks make sure Mom and Dad are broke beforehand so that Medicaid will take care of paying for their nursing care. But it varies by state as to whether or how much of this is allowed.

Best of luck to you in handling your situation.

[DBoon]

26. Not just "Mom and Dad are broke beforehand"

Make sure the kids are broke as well

[Hoyt]

3. That information is important. But the fact 19 million beneficiaries have voluntarily signed up and

continued, tells me they like it. Before I stopped working as a consultant, I had Kaiser Medicare Advantage for 2 years. I liked it a lot. Of course, I don't have serious health issues, and frankly don't care what doctors I get to see as long as they are good and I can sue them if they screw up. That's not for everyone, but Kaiser was cheaper than traditional Medicare with a decent supplemental.

They had restrictions on some drugs, but I'm fine with generics and could appeal if there were some real reason I had to have the more expensive stuff which probably isn't much better than a generic. One example -- they would not approve a brand name drug that you take once a day. They would only approve the generic that you had to take twice a day. The cost was like $300/month vs. $30. I was fine with the generic and know that Kaiser will use the savings somewhere else. That is not acceptable to a lot of patients, so they can buy an expensive drug plan and supplement. I figured Kaiser Medicare Advantage saved me at least $200 a month in premiums. The single pharmacy in my area was a pain, but just before I left they opened it up to other pharmacies for a slightly higher copay.

[airplaneman]

4. I see medicare advantage much like PPO vs HMO

Last edited Mon Jul 3, 2017, 01:19 AM - Edit history (1)

If you want to save money and are fairly healthy the HMO looks better. But if you are very sick or get very sick you find yourself short changed. Remember also medicare advantage does not include Hospice. I think it is bad overall for people to gravitate to the save a little if your healthy versus broad based protection for everyone.
JMHO
-Airplane

Edited as requested.
Hoyt wanted me to point out that
"The Medicare Advantage Plan doesn't cover Hospice, but traditional Medicare takes over if you have an Advantage plan. Thus, it's covered and you get Hospice either way."

And I am aware of that - what worries me personally is that if Republicans succeed in removing money from medicare and medicaid this may cease to be the case. In a sense medicare advantage is covering more because it does not pay for hospice. Medicare advantage is private insurance covering medicare but being paid for by the government. A long awaited data release that would prove if medicare advantage was an economical good idea has just been delayed.

[Hoyt]

9. The Medicare Advantage Plan doesn't cover Hospice, but traditional Medicare takes over

if you have an Advantage plan. Thus, it's covered and you get Hospice either way. It would be nice if you would changed that so as not mislead people into believing hospice benefits are not covered if you select an Advantage plan. Hospice is covered, and you get to select the program you want.

There are also a lot of people like me who prefer coordinated care if I get sick rather than having to find my own doctors -- cardiac specialist, surgeon, rehab, gastro, ortho, urology, psych, etc. -- who probably don't talk to each other. And if the Advantage plan is not meeting your needs, you can go back to traditional Medicare, although you may have to wait until certain time of the year.

[airplaneman]

14. see my edit n/t.

[Hoyt]

18. Thanks. Let's just say for a moment that MAdvantage costs a bit more, does that make it bad or good

because people like it and it combines drugs and a supplement for less cost than traditional Medicare, and you are free to choose? If it costs a bit more and is good for the 33% that choose it, it's not bad? I would not want it to detract from care for others, but it doesn't.

[crosinski]

29. These plans cherry pick healthy seniors by offering them low cost plans.

That leaves less healthy seniors for Medicare to take care of. As you know, for Medicare to work it needs a pool of healthy people paying in too. Advantage plans are a drain on Medicare.

[Hoyt]

30. Every one of those seniors can sign up for a Medicare Advantage Plan, there is nothing to keep them

from it. Medicare Advantage Plan budgets and costs are charged against the Medicare budget. It is a better deal for most Americans, but those who want to go to any doctor they choose no matter how the doctor's utilization is compared to peers, demand any drug they can without regard to the cost to the program, don't want to participate in proven care management programs for chronic disease, etc.

Advantage Plans are not a drain on traditional Medicare, because Advantage plans are Medicare -- 33% of Medicare beneficiaries looked at traditional Medicare and decided the Advantage Plans are the best choice for them. You see evidence of that right here.

Any Medicare recipient can choose a Medicare Advantage Plan. In fact, the government actually pays the advantage plan a little more to take the sickest beneficiaries and develop management programs for them. Further, the government monitors the quality of care of Advantage Plans much closer than the do the open Medicare program that will continue to pay doctors until they do something awful to a patient.

[crosinski]

35. Advantage plans are offered by private companies.

Last edited Mon Jul 3, 2017, 01:40 PM - Edit history (1)

There's no question about that.

There's no question that when I was ready to apply for Medicare and doing so online, I was asked to fill out brief questionnaires about myself and then was offered $0 cost Advantage Plans. I'm healthy. When it was my husbands turn, who is a diabetic and overweight, he wasn't so lucky. He was priced out of the market. I did this over and over again at so many different sites I lost count. As a matter of fact, they're all built about the same. So, I think that's a pretty good example of how a healthy person is 'funneled' toward a Advantage plan, and someone with health problems toward regular Medicare by default.

How many thousands of times do you think this happens a day? So, insurance companies get to cherry pick healthy seniors and Medicare gets the unhealthy seniors. Wealthy repugs get to line their pockets and Medicare takes a hit. Business as usual.

"In fact, the government actually pays the advantage plan a little more to take the sickest beneficiaries and develop management programs for them."

I'm not sure when an Advantage plan would get a chance to take these sicker patients you mention, unless they're well off. I don't think poorer sicker seniors are given subsidies to help pay for a private plan. Yet. :::Edit::: Medicare Advantage Special Needs Plans (SNPs) Ah - I see they do. Well then. It's a done deal, isn't it.

"Further, the government monitors the quality of care of Advantage Plans much closer than the do the open Medicare program that will continue to pay doctors until they do something awful to a patient."

Now, that's just silly. I don't think Medicare is the only one in charge of 'its doctors.' If a doctor causes harm, the whole system he or she works in has failed.

[Hoyt]

36. Sounds like your husband didn't sign up for an Advantage plan during open enrollment.

If he had, he wouldn't have been charged more. You can't scheme the system by waiting.

Yes, Medicare Advantage Plans are ranked by the government for quality of care. Measuring it even includes polling enrollees.

You don't have that in traditional Medicare. Never said Medicare was the only one in charge of doctors. I said Advantage Plans are monitored for quality, and that is true.

There are some issues if you decide to switch back to traditional Medicare after getting sick in that you can do it only at certain times of the year or if you move out of the plan area, but similar issues exist if you switch supplemental policies after getting sick.

[crosinski]

37. My husband signed up during open enrollment.

No scheming here. We simply couldn't afford the plans that were offered to him. LOL ... I guess we're poor compared to the people who can afford these plans, and I didn't need to learn that today, but there you go.

"Yes, Medicare Advantage Plans are ranked by the government for quality of care. Measuring it even includes polling enrollees."

Everyone thinks Advantage Plans are grand, until they get sick. Then rates go up. But, no problem, you can just plop back into good ol' Medicare when your health fails. You have to wait until open enrollment comes around again though, so bills might pile up. And if you missed your opportunity to buy Supplemental Gap insurance at low cost when you were 65, then that's out. Gosh, sure hope there's enough money left to cover everyone!

See how that works?

[Hoyt]

38. Anyone, including your husband, is guaranteed the right to enroll in any Medicare Part C plan

open to new enrollees in your state, regardless of his pre-existing condition, as long as they apply within six months of first enrolling in Medicare Part A and Part B. Again, they aren't going to let you take Medicare, buy no or an inferior supplement and then try to change to a better plan as soon as your costs start rising. I would not expect them to. But some people do.

If you wait after that, you might run into an issue. Apparently, that is the case here.

Your individual premiums do not increase next year because you got sick, sorry. They might go up for everyone in the plan, but that is true of any insurance and traditional Medicare for the Part B premium and the supplemental plan one has to buy to cover drugs and all the gaps Medicare leaves.

BTW -- I get it's tough any way you cut it when one of the family has a serious health issue. Hope things go well for you and your family.

[crosinski]

39. If you get sick, your premiums will raise, and so will your copays.

"Your individual premiums do not increase next year because you got sick, sorry."

According to several articles I've read, not only can your premiums increase, so can your co-pays.

"The Medicare Advantage plan may offer a $0 premium, but the out-of-pocket surprises may not be worth that initial savings if you get sick. “The best candidate for Medicare Advantage is someone who's healthy," says Mary Ashkar, senior attorney for the Center for Medicare Advocacy. "We see trouble when someone gets sick.""

Pitfalls of Medicare Advantage Plans | Investopedia [link:http://www.investopedia.com/articles/personal-finance/010816/pitfalls-medicare-advantage-plans.asp#ixzz4lnfxFIHI |

I've told my story in good faith. If you don't believe me at this point, then that's fine. However, I do hope people take a look at the options before they jump into an Advantage Plan, and consider what they are doing to original Medicare if they do. Do we want original Medicare to continue, or do we want to allow it to be pecked away by for profit insurance companies? And what have insurance companies done, exactly, to suddenly inspire our loyalty?

Original Medicare is a damned good program. It's affordable, portable, and it's all most people ever need.

[Hoyt]

40. Your Part B Medicare premiums increase each year, as do your supplemental and Drug policies.

I believe your story and how you decided to purchase traditional Medicare. Others in your situation have gone the Advantage way. That is what is nice about choice in this case. You can do either. I hope your choice works out for you, and suspect it will. I respect other peoples' choice too and that is Medicare Advantage with a cap on out-of-pocket expenses, small copays, drug coverage without having to spend another penny as you do with traditional Medicare.

Traditional Medicare is not being pecked away by Medicare Advantage -- that is my only issue with what you are saying. I guess you'd be happy if I, and 19,000,000 other Americans, have no choice but to go traditional Medicare and pay $200 - $250 a month extra for a decent supplement and drug plan.

[crosinski]

41. Hold it Hoyt - this report would tell us both what we want to know.

So why aren't they letting us see the data?

Maybe we should join forces and storm the Bastille, no?

[Hoyt]

42. Probably because it isn't finished. You can look up similar reports that have been done in the past.

What you'll find in those reports is that Medicare Advantage is cheaper than traditional Medicare in cities, and traditional Medicare tend to be a little cheaper in rural areas, not unlike ACA with skimpy networks in rural areas. Seems to me, having the choice is best under those circumstances. You can have tradional Medicare if you want, or join the 21st century and pay less for coordinated care. I prefer the latter and more modern system under non-profit Kaiser.

[crosinski]

43. I found one, and it's not so good.

Vast Majority of Private Medicare Advantage Plans Overcharged the Government
Posted in Budget, Medicare, Medicare Advantage By NCPSSM on 8/29/2016 2:12 PM

New analysis by the Center for Public Integrity of Medicare Advantage audits show that 35 of the 37 companies audited by the Centers for Medicare & Medicaid Services (CMS) overcharged the government by millions of dollars each year. By “upcoding” claims, insurance companies report patients as being sicker than they are and thus collect higher payments from Medicare.

By overstating the severity of medical conditions like diabetes and depression, extra payments are made to health plans which claimed some diabetic patients also had complications of the disease, such as eye or kidney problems. After the CMS audits, these claims were ultimately reduced or invalidated in nearly half the cases, sometimes more. This CPI report isn’t the first time private insurers in Medicare Advantage have come under fire. In May, a Government Accountability Office report called for “fundamental improvements” to curb excess charges linked to faulty risk scores. In addition, at least half a dozen health-industry insiders have filed whistleblower lawsuits that accuse Medicare Advantage insurers of manipulating risk scores to boost profits.

17 million seniors are enrolled in Medicare Advantage and in 2014, Medicare paid the health plans more than $160 billion. The Center for Public Integrity reported that overspending tied to inflated risk scores has cost taxpayers tens of billions of dollars in recent years.


I've made my original point, and now I've dug up this infuriating piece of info too, so I'm done with this discussion for now. But good luck to you and those super expensive meds you take. Our Part D Drug plans only cost about $30 each, so I feel for ya buddy.

Now I'll just climb back into my buggy and trot my horse back into the 20th century where you slyly implied I come from.

[Hoyt]

44. Go look up what traditional Medicare loses every year in fraud and abuse. It's a lot more than

that and they don't get most of it back as will happen in the audits above.

Besides, what you quoted has absolutely nothing to do with the relative cost of the two models.

Finally, I not trying to convince you that Medicare Advantage is better for you. I'm trying to say both models have their good points and will appeal to different people depending on what their situation and beliefs are. There's not much difference in cost to government, but there is a cost savings to those paying out of their pocket for premiums.

I liked Kaiser a lot compared to having to manage my various care needs, now or in future, myself. I'll let the experts do it. If I get diabetes, I'll sign up for the diabetes management program and come out better than most on traditional Medicare.



Keep your traditional plan in good health, but let me and 18 million others keep theirs.

[still_one]

23. I think your PPO verses HMO assessment is pretty much on target.

Medicare Advantage plans generally limit you to the doctors and facilities within the HMO or PPO, and may or may not cover any out-of-network care. Traditional Medicare and Medigap/supplemental policies cover you if you go to any doctor or facility that accepts Medicare. If you require particular specialists or hospitals, check whether they are covered by the plan you select.

Medicare Advantage plans often only operate with a certain region. If you live in more than one state throughout the year, traditional Medicare plus Medigap is probably a better choice than an Advantage plan. This may also be true if you travel frequently: Some Medigap plans provide coverage when traveling outside of the United States and cover you in all 50 states; Advantage plans generally do not.

What may be an issue for some is once you sign up for an Medicare Advantage plan you may not be able to go back to a Medigap/supplemental plan should your circumstances change without a physical to qualify

For some the decision will be governed by premium costs, though deductibles, and out of pocket expenses need to be factored in also.

[radical noodle]

5. There were some people in our community

who were on what they were told was a Medicare Advantage Plan but they were left high and dry when the company went under. Some docs in our area of Florida will take Medicare but not Medicare Advantage. When it comes to health insurance at our age, I want safety and to know we won't have any last minute surprises. JMHO

[Marthe48]

6. My husband had BCBS Freedom Blue PPO

He was diagnosed with cancer in March 2016 and passed away Jan. 2017. So far, we've had to pay only about $1000.00-$2000.00 co-pays. It'll take awhile for the hospital to finish wading through billing, but I got statements from the insurance companies and haven't had any terrifying amounts. Knock wood.

I am getting ready to get Medicare, and I chose the same plan. I'll pay under $130.00 for it and under $140.00 for Medicare. I'll save about $250.00 monthly from what I'm paying now, which is provided through my husband's pension plan. I consider myself healthy, but John thought he was doing ok too.

Anyway, for what it cost the last year, chemo and hospital stays, feeding tube and supplies, the ins. was worth it.

[angstlessk]

7. Does Medicare include emergency room visits?

[PennyK]

10. Yes.

Just go to Medicare.gov to see what's covered.

I was diagnosed with breast cancer several months after turning 65 and getting regular Medicare, along with a supplemental Plan F. I've had many tests, chemo (and the expensive Neulasta shot after each one), radiation, two surgeries, a few complications, including a blood transfusion and hyperbaric oxygen treatment for a wound after my surgery area became infected, and I don't think I've spent $100 of my own money (not counting medications).
And in a couple of months when I'm all healed up, Medicare will cover my breast reconstruction, too.

[Hieronymus]

13. Medicare is great,and

the Right wants take it away. They try to put it down.

[Honeycombe8]

17. My goodness, you had a run of bad luck, there! Glad to know you're doing well, now, tho. nt

[Delmette2.0]

11. In my experience, yes.

My mother and disabled son are both on Medicare and have had emergency room visits. Mom has BCBS supplemental insurance and my son has Medicaid for supplemental insurance. Neither one has had to pay out of pocket expenses.

[angstlessk]

12. I ask, because I broke my shoulder

went to the emergency room...they of course xrayed my shoulder, but also my chest, and did a cat scan????

I asked about the cat scan, and the answer was that just because my shoulder was broken, I could have had a head injury????

I walked away with a sling, and some aspirin (they wanted to give me morphine which I refused).

Had I known there was no fix for a broken shoulder, I had scarves to use as slings, and plenty of aspirin at home!

[Deuce]

15. Hmm, never knew you couldn't fix a broken shoulder. Thanks for the info!

[angstlessk]

25. Sorry, it was my collar bone

[Honeycombe8]

16. I don't know how you'd determine what "over charging" is, though.

Since it's for profit, they are sort of free to make their own rules, aren't they?

My brother just signed on with Medicare. He got Plan F, the MediGap, and is happy with it.

[PennyK]

22. Yes, Plan F is the best

We do pay more every month for our coverage, but as I said above, so far, no matter what doctor I see, or where I've been treated, I have paid nothing out of pocket. Even my eye doctor worked out a way to have my regular vision checkups almost totally covered (I actually paid more when husband was still working and we had his very good coverage).
Medicare is great.

[still_one]

24. You are right Penny, Supplemental Plan F is the most flexible for choice. You aren't limited

where you can go within the 50 states to places that accept Medicare. Also, there is much less hassle if you want to see a specialist. You are paying a higher premium, which tends to go up every year.

Eye exams for the health of the eye, such as checking for glaucoma or other issues, are included in a Medicare Supplemental F policy. However, getting fitted for glasses is not usually covered under a supplemental Medicare plan, so if you are able to work with your physician on that, you fortunate.

[Honeycombe8]

28. I'm going to do my best to be able to pay for that, when I get Medicare.

A friend of mine recommended that to me years ago, and I checked into that, and that is the way to go. Well worth the money. She had all sorts of surgeries & medical treatments, and paid almost nothing. Fully covered.

My brother is very happy with it so far. I figured out my retirement budget, and looks like I can afford it (if I don't decide to take up an expensive hobby).

What a comfort it is, knowing that that is there. We now need Medicare-for-all and stop jacking around with all these reforms and repeals.

[crosinski]

32. Just because it gets confusing, Medigap and Advantage Plans are not the same.

Just wanted to pipe up about that.

Medigap insurance is also called Supplemental Insurance. Medigap policies are: A, B, C, D, F, G, K, L, M, N

Medigap insurance helps pay for the 20% that Medicare doesn't cover, and everyone has a chance to buy it very inexpensively when they turn 65. It's perfectly legitimate insurance and doesn't undermine Medicare in anyway.

I think your brother made an excellent choice.

Advantage Plans pretend to be Medicare but are private for profit insurance. They cherry pick healthy seniors and destabilize Medicare.

[Honeycombe8]

45. Interesting. I did not know that about Advantage. nt

[LarryNM]

19. Employer Covered Medicare Advantage

for 2 of us through Humana. No Supplemental allowed. So far, so good.

[voteearlyvoteoften]

27. Medicare Advantage good for area you live in

But if you say spend winter down south it won't cover you out of area. Insurance agent told me.

[Desert grandma]

31. Love original Medicare

Both spouse and I are on original Medicare with plan G supplement. Plan F is being phased out and will no longer be offered to new enrollees in 2020, or we would have chosen that plan. We enrolled in plan G (very similar to F except does not pay deductible..currently $183.00) because we felt as new seniors in 2020 are kept from enrolling in plan F, the pool shrinks which will inevitably result in higher premiums as only older and sicker people are left in plan F. Also, we discovered that Medicare Supplement plans are rated differently. Age attained plans ( which are the majority of plans), base premiums on your age as well as inflation, so that as you age premiums will increase. Age issue plans base premiums on the age you are when you enroll in the plan. Thus the earlier you enroll in such a plan, the less expensive it is. Age issue plan premiums only increase due to inflation, not to increasing age. Most medigap plans are "age attained" plans. We found only one, Transamerica, that is an "issue age" plan available in our area. We have been extremely happy with it. It also gives us choice in choosing providers, as we are not committed to a "network". Since the plan pays any additional amount that is over the 20 percent left after Medicare pays, we can also use the Mayo clinic and other national medical centers if we choose to. Once we pay the first $183.00, we pay no other co-pays or deductibles. I discovered this information after much research. Medicare.gov does have the information, but you have to search for it.

[Bayard]

33. Wouldn't this violate HIPAA?

Health Insurance Portability and Accountability Act (HIPAA), which guarantees right to privacy of medical records?

[Vinca]

34. I have original Medicare and I'm really happy with it.

In May I had a routine colonoscopy that resulted in pathology fees for some polyps (benign, thankfully) and the out-of-pocket cost for the procedure and everything associated with it was less than $350. As a person who has been self-employed for decades, $350 out-of-pocket is like a bargain basement sale.