By Brenda Gazzar
Code Wack Podcast, October 11, 2021
Part one of a two-part podcast featuring Dr. Ed Weisbart, national board member and Missouri chapter chair of Physicians for a National Health Program, discussing the differences between traditional Medicare and Medicare Advantage plans. Plus, why should we be concerned about the impact of Medicare Advantage plans on the Medicare Trust Fund?
Transcript
Welcome to Code WACK!, your podcast on Americaâs broken healthcare system and how Medicare for All could help.
It seems like Medicare has been popping up in the news lately, in good ways and bad! But whatâs always true is that our country struggles between treating health care as a public good and treating it as a profit-making venture. This conflict of visions is very apparent when comparing traditional Medicare to Medicare Advantage plans. Dr. Ed Weisbart, a retired family physician, former chief medical officer of Express Scripts and a national board member of Physicians for a National Health Program, is joining us today to talk about the latest attack on Medicare â and what we can do about it.
Q: Welcome to Code WACK!, Dr. Weisbart. So letâs talk about traditional Medicare versus Medicare Advantage. What are the main differences between these that consumers should know about?
Weisbart: So theyâre really two entirely different programs. Traditional Medicare is a public program paid for straight through our tax dollars to the Medicare program and then Medicare, traditional Medicare, has relationships with doctors and hospitals and everything so itâs just nice and is clean. Medicare pays the doctors and hospitals.
Medicare Advantage is completely different. The people who have chosen to go into Medicare Advantage, Medicare no longer pays doctors on your behalf. Medicare no longer pays the hospitals on your behalf. Instead, Medicare pays an insurance company, a Medicare Advantage insurance company, Humana, Blue Cross. Thereâs many of them but they pay the insurance company and then you have whatâs very similar to employer-style insurance, and that means that they can tell you which doctors you can and canât go to. Traditional Medicare doesnât do that. Medicare Advantage can tell you which hospitals you can and canât go to. Traditional Medicare doesnât do that, only Medicare Advantage does that. So, Medicare Advantage, you have a group in between you and Medicare, whose mission is a business mission trying to find a way to make a profit off of you being sick and such. That doesnât belong in health care.
Q: So it sounds like (itâs) very similar to having private insurance.
Weisbart: It is â except thatâs nowhere near as good as traditional Medicare. So really from a consumerâs point of view thereâs probably three important things to consider ⊠between traditional Medicare and Medicare Advantage. The first is a difference in coverage, the second is a difference in access, the third would be a difference in cost as a consumer, so the coverage in theory is the same, right? Traditional Medicare and Medicare Advantage plans both cover the same benefit package of whatâs medically necessary, although in traditional Medicare you have a lot more doctors and hospitals to pick from. Medicare Advantage plans do cover the same range of benefits, but they get to decide whatâs medically necessary and they may make different decisions. They have a business interest in making different decisions so they could take a narrower view of what is actually necessary than traditional Medicare does. The coverage is technically the same, but in real life the coverage for Medicare Advantage is not the same as in traditional Medicare.
The second difference is access, as I was alluding to with traditional Medicare you can go to any doctor or hospital that takes it which is like 93% of adult medicine doctors and you donât need a referral. You donât need to ask for permission. You donât need to get prior authorization. If you want to go to a doctor thatâs in Medicareâs network, you can go to that doctor , thatâs almost any doctor and hospital, whereas Medicare Advantage, you typically have to get a referral typically from your primary care physician or from the Medicare Advantage plan, or itâs, if youâve given up your traditional Medicare, and youâve gone into Medicare Advantage, you want something thatâs probably expensive because youâre that sick, you suddenly have to start getting permission and approval. Thatâs not treating you like an adult. Thatâs taking away your choice.
But the third difference is the cost difference as a consumer. With traditional Medicare there are copays and deductibles and so people who can afford to do it typically will buy a Medigap policy to take care of the copays and deductibles and if you do that, and youâve got pretty darn good health insurance with traditional Medicare.
With Medicare Advantage, itâs different. You canât buy a supplemental policy to go on top of Medicare Advantage. So when Medicare Advantage Plans charge you copays and deductibles, you canât buy Medigap to cover that. If the Medicare Advantage plan says youâre going to have to pay all the costs for your out of network care, you want to go to the doctors across town instead of this side of town. Youâre on vacation in Florida or wherever, and you want to go to the doctor there, and the Medicare Advantage plan says thatâs out of network and is not covered, or theyâre only going to pay half or what have you, you cannot buy insurance to supplement Medicare Advantage. So, in Medicare Advantage thereâs actually a limit to how much it can go. You canât have more than $7,550 in out of pocket expenses.
Thatâs a lot of money. There is no limit like it in traditional Medicare because if you buy a supplement, youâve got almost no out of pocket costs, no matter whatâs going on. So the reason people often pick Medicare Advantage if they do is because the premiums are lower than a Medigap supplement, so you can look at a Medicare Advantage plan, look at the low premiums and think âIâm indestructible, Iâm not going to get sick. I donât have to worry about if I get sick.â âWell, why are you buying insurance in the first place,â but they think that. They see the lower premium but they donât realize that that comes with an exposure to now nearly $8,000 in out of pocket expenses, an exposure that doesnât exist in traditional Medicare if you buy a supplemental policy, usually a couple couple hundred bucks for the supplemental policy which is not cheap but if you buy that, then you donât have exposure at all.
The trade off is do I pay the premium for a supplemental policy of maybe a couple 100 bucks a month or do I avoid that but risk if I get sick having thousands and thousands of dollars out of pocket? So Medicare Advantage is a way worse deal.
Q: Wow right. Thatâs very interesting and we are talking about, you know, the sickest population, the over 65 is among the sickest in the country. Okay, how do the programs differ from a doctorâs perspective?
Weisbart: The differences from a doctorâs perspective are pretty similar to the differences from a patientâs perspective, in the sense that traditional Medicare is really easy to deal with, right, itâs really easy to deal with. If a patient comes in to see you and they have traditional Medicare at the end of the visit, we submit our bill to Medicare, and before too long Medicare pays the bill and thereâs very little second guessing. Thereâs very little denials, very little of any of that stuff. So traditional Medicare from a doctors point of view is great. I can do the work that I need to do. I donât have to worry about where to send my patient. If I have a patient that needs radiology and Xray needs surgical centers or something done, pretty much all of those places take traditional Medicare and take the supplement so I can send my patients to the place that I think is the best for them.
Medicare Advantage is a whole different thing. (With) Medicare Advantage, you know, they have a game of delaying when they pay you, arguing down how much theyâll pay, saying âno, thatâs not medically necessary, weâre not going to pay for it. Oh, you sent your patient to that radiologist â not so fast doctor we like this radiologist,â and you know itâs a nightmare and the doctor may not know which one it is, so the patient goes there and then comes back and has to tell us âgosh, doc you sent me to the wrong place,â well how am I supposed to know? Itâs a nightmare. With Medicare Advantage, itâs frankly a nightmare for me and traditional Medicare from a doctorâs perspective is a breeze.
Q: Wow, thank you. In terms of health policy, what are the implications of having two competing programs when it comes to healthcare equity?
Weisbart: So, whenever you set up two different systems that compete against each other and theyâre not really comparable, you have a disaster on your hands. So from a health policy perspective what weâve done is weâve created one option thatâs designed to make profit for private commercial industry, and another enterprise thatâs designed to improve the health of people, and as a result the for-profit one, well they want, the Medicare Advantage plans, well they want to find the healthiest people they can. If youâre actually genuinely sick, they donât want you. Itâs called cherry picking. Theyâre trying to find the healthiest people. If you are actually sick they donât want you there, thatâs called lemon dropping, and then once theyâve got the healthiest group of people, they want to make that group of people look sick. They want to find the more diagnoses, the more crazy things that they can find so that they can charge the government more. They can charge Medicare more, so from a health policy perspective, what we have is the Medicare Advantage plans are literally draining the Medicare Trust Fund.
When you hear the Medicare Trust Fund is in trouble, thatâs not because of Medicare, thatâs because of Medicare Advantage, so theyâre draining the Medicare Trust Fund and when you do that, then of course that means that the premiums that seniors have to pay or Medicare people have to pay for part B, go up. So if somebodyâs trying to find more profit in the system, they either have to block your health care which is of course what Medicare Advantage plans are designed to do, or they have to drain more money out of the system by draining the Medicare Trust Fund and resulting in higher premiums. So itâs a terrible idea. Itâs a terrible idea.
And we talked about health equity and one of the areas of health equity thatâs not fully recognized, I donât think, is the problem with rural communities. We know that people who are sick are more likely to want to get out of Medicare Advantage once theyâve gotten sick. People in rural communities are twice as likely as people in nonrural communities to want to get out of Medicare Advantage. You go in because like I said the premiums are lower because weâve so overpaid in Medicare Advantage, that they can afford to throw a few pennies at us for the premiums so the premiums are lower, so you go into it when youâre sick and especially, especially if youâre in an underserved kind of community, a rural community or any other underserved community. Thatâs not where the Medicare Advantage plans have their networks, because they put their networks in the most profitable areas not the sickest areas.
So, from a policy perspective, it does not accomplish our goals. Traditional Medicare, good-old fashioned Medicare that weâve had since 1965, thatâs done a phenomenal job at controlling the cost of health care, at rescuing seniors from bankruptcy and from poverty, at giving seniors wide choice over their own health care, and at actually making seniors healthier, and frankly, very little of that is true for Medicare Advantage.
Thank you Dr. Ed. Weisbart. Join us next time when we talk about the latest sneak attack on traditional Medicare.
Find more Code WACK! episodes on ProgressiveVoices.com and on the PV App. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for health care reform around the country. Iâm Brenda Gazzar.