The Results are In: There is a Price to Pay with Some Medicare Advantage Plans

Joe Casciani, PhD

My Experience with Medicare Advantage Plans

As a geropsychologist, I have worked with traditional Medicare, Medicare Advantage (“MA”) plans, HMO’s, and Medicaid insurance programs for patients in skilled nursing and residential facilities. Fortunately, traditional Medicare benefits (and Medicaid to a lesser extent) include mental health assessment and treatment for medically necessary services. MA plans and HMO’s, on the other hand, were another story. For patients enrolled in these “managed” plans, mental health services were typically not authorized, sharply restricted, or could be delivered only by a single practitioner – usually on the other side of town. Facilities were also stymied by the service restrictions imposed by these managed plans, so there was nothing unique about mental health services. The familiar refrain was that the managed plans worked fine for the healthy but didn’t work so well when you got sick.

As attractive as they may seem, research is showing the true cost of selecting a low priced Medicare Advantage plan. Since their inception decades ago, these plans have offered a low-cost alternative to traditional Medicare and Medigap policies. Because premiums are lower with Advantage plans (lower costs are possible because these plans receive a per-enrollee fee from Medicare), they are very attractive to consumers in the U.S. However, a study newly released by the National Bureau of Economic Research tends to indicate that, when compared with those enrolled in traditional Medicare, there is a higher incidence of earlier deaths in Advantage enrollees. The research team from Yale School of Management, Brown University, University of Chicago, and Northwestern University looked at more than 75,000 plans, and 15 million enrollees, and compared mortality rates among the plans.

The main findings:

• If enrollees in the plans with the 5% highest mortality rates moved to a plan with lower mortality rates, there would be ABOUT 10,000 OR FEWER DEATHS A YEAR.
• If everyone were to move to a plan with the lowest mortality rate, the NUMBER OF DEATHS WOULD DECLINE BY 26%.
• Higher premium plans and those plans with more generous drug coverage have lower death rates.
• Those plans that spend more on clinical care rather than overhead and marketing had lower mortality rates. (Free dinners anyone?)

Recommendations When Selecting Plans

The writer who reported this research, Carla Fried, recommends, of course, that shoppers look at more than low price. Starting with a low premium may be a mirage, according to Ms. Fried. And a good understanding of the trade-offs is essential when selecting an Advantage plan versus traditional Medicare and Medigap coverage. Another little known fact about these plans concerns pre-existing conditions: only in the initial selection in an insurance plan are pre-existing conditions excluded when  calculating premiums. But, upon switching to a different plan after this initial window, age and pre-existing conditions are considered when determining monthly premiums for the Medigap policy when moving into traditional Medicare.

Shoppers are also advised to see if their doctors are on the panel of the MA plan, since historically they confine their panels to small networks. And, when weighing the costs and benefits of any plan, find out about what services will require prior authorization.

Lastly, but most important, be prepared to appeal denials. A government audit found that in these MA plans, appeals were overturned 75% of the time, and that many MA plans overturned their own initial denials 90% of the time. Smells like, tastes like, feels like, and looks like a bottleneck to me: create barriers to care, but let through the most persistent and tenacious.

Living to 100 does involve doing everything we can to stay healthy, and weighing all factors when deciding on the availability of good health care. Of course, we cannot always stay healthy, but we can do our best to make the right choices as far in advance as possible. And, despite some of the findings reported in this article, most MA plans are good and worth considering, and may be the best option for a consumer. Just the same, caveat emptor.

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