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VIEWPOINT: Medicare Advantage plans: Are we doing our best for our seniors?

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Medicare provides health insurance coverage for 65 million people in the United States.  But Medicare has changed, and today, over 30 million seniors, (nearly 51%) are covered under a Medicare Advantage Plan. The number of Special Needs Plans available has doubled since 2018.  Even government retirement packages are looking at Medicare Advantage as an alternative. It is well known that in Delaware, state retirees are facing a considerable battle over being forced into a Medicare Advantage Plan as opposed to the promised benefits of traditional Medicare and supplemental insurance coverage.

Dr. Glenn Brown

Given the increasing popularity of Medicare Advantage, we must consider how and if this transition in the Medicare market is beneficial to both patients and providers. Significantly, we must consider the impact of the rising percentage of the Medicare market share captured by for-profit companies versus nonprofit, or government plans. Currently, for-profit insurers account for 72.9% of all Medicare Advantage plans, with an annual growth rate of over 11%.

Medicare Advantage plans purport additional benefits and coverages for subscribers compared to traditional Medicare. These plans boast lower prices for prescription drugs and lower premiums with expanded coverage options such as vision, fitness, telehealth, hearing, and dental benefits. Despite these additional bells and whistles, beneficiaries in Medicare Advantage and traditional Medicare reported similar rates of satisfaction with their care. Regarding affordability, a slightly smaller number of beneficiaries in traditional Medicare with supplemental coverage than Medicare Advantage enrollees reported having cost-related problems.

However, many Medicare Advantage plans create cost and convenience issues for subscribers. These include limited network coverage, high out-of-network costs, prescription drug formularies that do not include their needed medications, preauthorization, and utilization management processes that can lead to delays in care and administrative burdens for both patients and health care providers. In my practice, Highmark Medicare Advantage subscribers encountered an unexpected increase in out-of-network copayments. These copayments, which previously were 20% co-insurance payments, now range from $35 to $50 per visit depending on the plan selected by the subscribers.

While there are pitfalls for subscribers in Medicare Advantage, the challenges it creates for providers are so great that many providers are unwilling to accept their fee schedules and billing/reimbursement policies. Large provider groups are leaving the Medicare Advantage market because of low reimbursement and prior authorization hassles. Providers also experience much greater complexity in the billing and collection process which involves greater resources allocated to obtain payment for services. They expose themselves to greater financial risk because of the increase in complexity and the risk of unpredictable plan changes, including reimbursement rates, utilization management programs, and other billing and collections process burdens.

Medicare Advantage plans give the perception of being an appealing alternative to traditional Medicare. These plans promise additional benefits and cost savings, but they also come with a range of disadvantages. These disadvantages include limited network coverage, higher out-of-pocket costs, geographic and prescription drug restrictions, and the potential for plan changes and disruptions. Additionally, a growing number of Medicare subscribers are covered by “for-profit” companies. Recent evidence indicates that “for-profit” consolidated companies result in elevated physician charges and costs. Prudent and forward-thinking decision-making must occur now.

We must drive more of these plans back to traditional Medicare or at least force them to operate in a manner similar to traditional Medicare. Failure to do so will result in these profit-driven companies creating a system that transfers greater costs to those on a fixed income and greater limitation of provider access for a population that has notably more serious conditions and/or multiple medical issues. We owe it to our seniors to create a system that properly cares for them versus a system that sees only the gold in the “Golden Years”.

Dr. Glenn Brown DPT, MMSc, ATC, SCS is the co-owner of CORE Physical Therapy in Dover. He has been in clinical practice for 38 years as a physical therapist and athletic trainer and has been a sports certified specialist since 1993. Brown currently serves as the legislative chair of the Delaware Chapter of the American Physical Therapy Association.


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