Hospital Ads May Mislead
By Trudy Lieberman
By Trudy Lieberman
Rural Health News Service
This New York City subway ad recently caught my attention: “When researching hospitals, consider how much research they do.” The ad for Mt. Sinai Health System advised riders that the research “we do today drives medicine we will do tomorrow,” and the hospital system was proud that it ranked among the top four medical schools in the country in research dollars per investigator.
I’m used to outlandish and questionable advertising, but this ad rose to a new level.
If I were looking for a hospital for a surgical procedure or were taken to a facility in critical condition as I was in 2017, the last thing I’d care about was that the hospital ranked highly for “research dollars per investigator” – whatever that means.
How does implying that the research a hospital conducts today, which will take years to benefit patients if it pans out, indicate the hospital is currently giving superior care?
Why is this something I need to know before choosing a hospital? I can think of several other measures – like a hospital’s infection rates for bloodstream or surgical-site infections or its readmission rates – that can indicate poor care and are far more useful. These metrics are sometimes available on state health department websites or on the Medicare Hospital Compare site.
This kind of corporate hospital advertising falls into the same bucket as ads that tout medical miracles for hard-to-cure patients that occurred in the hospital paying for the ads. You’ve probably seen those, too. For months New York Presbyterian Hospital promoted the story of a little girl whose case was rejected by other hospitals but who was made cancer-free at its facility.
The Cleveland Clinic is a master at such ads. A recent commercial featured a woman whose heart was failing. She told viewers the clinic saved her life. “No one else could figure out what was wrong with me.”
What’s wrong with that testimonial? “The problem with these ads is they may not be giving a realistic picture to people who have serious life-threatening cancers and other diseases and suggest that survival, if not certain, is at least likely” at the hospital sponsoring the ad, says Arthur Caplan, a professor of bioethics at New York University's Langone Medical Center.
Those ads are misleading, Caplan told me. He explained that many ads push individualized or personalized medicine so patients think that the medications or treatments are designed specially for them. “They give the impression there’s a pharmacy up in the attic brewing up a medicine just for you.”
That’s deceiving the patients, Caplan noted. “It’s cruel to suggest you’re getting something special or otherwise unattainable when that’s not the case.”
These ad campaigns designed to make you think favorably of a hospital are part of a larger campaign to build brand recognition much like detergent or cereal makers do. “Medicine is mainly being treated like a business,” Caplan explained. “More and more, people are treated as customers, and doctors are treated as providers. You’d be a sap if you don’t advertise. I see a lot of cut-throat competition.”
Such brand recognition advertising is especially important when what Caplan calls "the Mother Ship Hospital" buys smaller facilities in other locations as a way to bring in more patients. When people live in communities where, say, a hospital like New York’s Mt. Sinai or the Cleveland Clinic has bought a satellite facility, they’ll think favorably about someday being a patient at the local affiliate.
But are care and outcomes at the satellites the same as they are at the Mother Ship, either good or bad? Patients can never tell from the advertising. A recent study published in JAMA Network Open found that the likelihood of surviving complex cancer surgery appears to be greater for those who had the procedure at the top-ranked hospitals than it does at their affiliates.
Until we know more, the best advice is to take hospital advertising with a grain of salt. Do research on your own if you are in a situation where you can make a choice – many people can’t – using the Medicare Hospital Compare website and any state information. You might also consider information on leapfroggroup.org, a nonprofit patient safety organization, to help with your decision-making.
What is important to you when choosing a hospital? Write to Trudy at trudy.lieberman@gmail.com.
By Trudy Lieberman, Rural Health News Service, Feb. 24, 2019
Solicitations for Medicare Advantage plans once again have been arriving in the mail, promising the best bargain since sliced bread. A case in point is one from Emblem Health, a managed-care company in my area that says it considers me what they call a “candidate” for their “special needs plan.” I don’t qualify for such a plan.
The solicitation was interesting, though, for what it promised. Free transportation to and from doctor, hospital, and lab appointments, but only up to 24 one-way trips a year. It also promised “no referrals.” Did that mean no referrals were necessary to visit specialists? The solicitation didn’t say.
That seemed highly unusual for what I am assuming is a Medicare Advantage HMO. HMOs usually require consumers to obtain referrals to specialists.
But shoving aside the questionable advertising pitches such solicitations are known for, that one reminded me that beneficiaries are now in a special enrollment period until the end of March. The special enrollment period, which began Jan. 1, gives seniors a three-month window during which they can switch some of their Medicare arrangements.
It’s also a good time for those who will soon be turning 65 to begin thinking of their options and learn what the rules are once they make their selections.
Until the end of March, if you have a Medicare Advantage plan, you are allowed to switch to another Medicare Advantage plan. Or you can drop a Medicare Advantage plan, return to traditional Medicare and buy a Part D stand-alone drug benefit, says Tricia Neuman, a senior vice president of the Kaiser Family Foundation and a Medicare expert.
What you cannot do, if you have traditional Medicare along with a stand-alone drug plan, is switch to a new drug benefit that might let you save more money on your prescriptions. You can do that only during the open enrollment period in the fall.
Keep in mind that if you drop a Medicare Advantage policy and switch to traditional Medicare, you might have trouble buying a Medigap policy to fill in holes in Medicare coverage. Only four states have what’s known as guaranteed issue Medigap insurance. In New York, Connecticut, Maine, and Massachusetts, people dropping Advantage plans in favor of traditional coverage can buy a Medigap even if they have preexisting conditions. In other states they may not be able to do that.
When might it be useful to consider other options during this brief window for switching?
If you have an Advantage plan that has a drug benefit built in as part of the coverage but you believe you can do better with another plan’s drug benefit, then you might want to do the math and see if a switch helps the budget.
Too many consumers fail to do their shopping for the drug benefit when, in fact, they can save thousands of dollars in pharmaceutical expenses by choosing one plan over another.
This special enrollment period gives you a second chance to save on drug costs.
But you may want to switch Medicare Advantage plans or choose traditional coverage, for other reasons that are becoming clearer. Research is beginning to surface that shows Medicare beneficiaries with high medical needs may have trouble accessing care in some Medicare Advantage plans.
Medicare defines those with high needs as people who have three or more chronic diseases and a functional limitation in activities of daily living or in performing routine daily tasks.
The U.S. Office of the Inspector General reported last fall that those with Medicare Advantage plans sometimes had trouble getting claims paid under those plans, or they reported other problems getting help from the plan.
The inspector general said that because so many seniors now have these plans, even low rates of inappropriately denied payments or services could cause “significant problems” for beneficiaries and their medical providers.
Just last month new research reported in JAMA Internal Medicine found that Medicare beneficiaries with high medical needs and those eligible for both Medicare and Medicaid were much more likely to disenroll from Medicare Advantage plans than other beneficiaries.
Researchers at Brown University and Columbia University found that disenrollment from Advantage plans “may indicate that plans do not meet the preferences of enrollees with significant chronic illness.”
This study and the inspector general’s findings offer a cautionary tale for people who will be new to Medicare in the coming months and for sick beneficiaries in Medicare Advantage plans who may want to reevaluate their options during this special open enrollment and next fall when open enrollment comes around again.
What has been your experience in choosing health insurance for this year? Write me at trudy.lieberman@gmail.com.
This New York City subway ad recently caught my attention: “When researching hospitals, consider how much research they do.” The ad for Mt. Sinai Health System advised riders that the research “we do today drives medicine we will do tomorrow,” and the hospital system was proud that it ranked among the top four medical schools in the country in research dollars per investigator.
I’m used to outlandish and questionable advertising, but this ad rose to a new level.
If I were looking for a hospital for a surgical procedure or were taken to a facility in critical condition as I was in 2017, the last thing I’d care about was that the hospital ranked highly for “research dollars per investigator” – whatever that means.
How does implying that the research a hospital conducts today, which will take years to benefit patients if it pans out, indicate the hospital is currently giving superior care?
Why is this something I need to know before choosing a hospital? I can think of several other measures – like a hospital’s infection rates for bloodstream or surgical-site infections or its readmission rates – that can indicate poor care and are far more useful. These metrics are sometimes available on state health department websites or on the Medicare Hospital Compare site.
This kind of corporate hospital advertising falls into the same bucket as ads that tout medical miracles for hard-to-cure patients that occurred in the hospital paying for the ads. You’ve probably seen those, too. For months New York Presbyterian Hospital promoted the story of a little girl whose case was rejected by other hospitals but who was made cancer-free at its facility.
The Cleveland Clinic is a master at such ads. A recent commercial featured a woman whose heart was failing. She told viewers the clinic saved her life. “No one else could figure out what was wrong with me.”
What’s wrong with that testimonial? “The problem with these ads is they may not be giving a realistic picture to people who have serious life-threatening cancers and other diseases and suggest that survival, if not certain, is at least likely” at the hospital sponsoring the ad, says Arthur Caplan, a professor of bioethics at New York University's Langone Medical Center.
Those ads are misleading, Caplan told me. He explained that many ads push individualized or personalized medicine so patients think that the medications or treatments are designed specially for them. “They give the impression there’s a pharmacy up in the attic brewing up a medicine just for you.”
That’s deceiving the patients, Caplan noted. “It’s cruel to suggest you’re getting something special or otherwise unattainable when that’s not the case.”
These ad campaigns designed to make you think favorably of a hospital are part of a larger campaign to build brand recognition much like detergent or cereal makers do. “Medicine is mainly being treated like a business,” Caplan explained. “More and more, people are treated as customers, and doctors are treated as providers. You’d be a sap if you don’t advertise. I see a lot of cut-throat competition.”
Such brand recognition advertising is especially important when what Caplan calls "the Mother Ship Hospital" buys smaller facilities in other locations as a way to bring in more patients. When people live in communities where, say, a hospital like New York’s Mt. Sinai or the Cleveland Clinic has bought a satellite facility, they’ll think favorably about someday being a patient at the local affiliate.
But are care and outcomes at the satellites the same as they are at the Mother Ship, either good or bad? Patients can never tell from the advertising. A recent study published in JAMA Network Open found that the likelihood of surviving complex cancer surgery appears to be greater for those who had the procedure at the top-ranked hospitals than it does at their affiliates.
Until we know more, the best advice is to take hospital advertising with a grain of salt. Do research on your own if you are in a situation where you can make a choice – many people can’t – using the Medicare Hospital Compare website and any state information. You might also consider information on leapfroggroup.org, a nonprofit patient safety organization, to help with your decision-making.
What is important to you when choosing a hospital? Write to Trudy at trudy.lieberman@gmail.com.
Drug company payments to doctors may influence their choice of what drugs to prescribe, and that can cost patients real money
By Trudy Lieberman
Rural Health News Service
Peggy, an Indiana woman and reader of this column, recently sent me a lengthy email about her 94-year-old mother who is rapidly spending down her minimal savings to pay for prescription drugs.
Peggy didn’t hold out much hope that prices would come down before it was too late for her mom. But she succeeded in lowering her mom’s drug costs, and what she learned along the way can be helpful to others strapped by high pharmaceutical bills.
Her mother is typical of many women in old age who have only a tiny financial cushion to absorb the continual price hikes imposed by the drug makers. She was raised during the Depression, didn’t work much outside the home, lived in a condo her son bought, and then moved to an assisted-living facility almost two years ago.
The facility’s $3,100 monthly fee, plus drug copays, bit into her savings, which totaled about $30,000 when she moved to assisted living. Government benefits earned by Peggy’s father who served in the Korean War, a very small pension from a former employer, and Social Security benefits cover all but about $600 of the assisted-living fee. The rest comes from her savings, which now are about half what they were in 2017.
By Trudy Lieberman
Rural Health News Service
Peggy, an Indiana woman and reader of this column, recently sent me a lengthy email about her 94-year-old mother who is rapidly spending down her minimal savings to pay for prescription drugs.
Peggy didn’t hold out much hope that prices would come down before it was too late for her mom. But she succeeded in lowering her mom’s drug costs, and what she learned along the way can be helpful to others strapped by high pharmaceutical bills.
Her mother is typical of many women in old age who have only a tiny financial cushion to absorb the continual price hikes imposed by the drug makers. She was raised during the Depression, didn’t work much outside the home, lived in a condo her son bought, and then moved to an assisted-living facility almost two years ago.
The facility’s $3,100 monthly fee, plus drug copays, bit into her savings, which totaled about $30,000 when she moved to assisted living. Government benefits earned by Peggy’s father who served in the Korean War, a very small pension from a former employer, and Social Security benefits cover all but about $600 of the assisted-living fee. The rest comes from her savings, which now are about half what they were in 2017.
While most of her mother’s drug copays and other out-of-pocket pharmaceutical expenses have been manageable, Peggy explained that it was the $313 copay for a three-month supply of a well-known, heavily advertised blood thinner, which a cardiologist had ordered, that was the biggest culprit depleting her mother’s savings.
That was the price her mom was paying when she hit Medicare’s infamous “donut hole” last year.
Peggy said that every time her mom visited the physician, the doctor told her she was lucky to take the expensive blood thinner instead of the other “stuff” which he called “rat poison,” implying a cheaper drug was inferior, even dangerous. Peggy said that at every visit, he said she was fortunate to be taking something better.
Then a family member discovered openpaymentsdata.cms.gov, a database maintained by the Medicare program that reveals the money pharmaceutical companies pay doctors in speaking, research and consulting fees, and for food and drink expenses. Her mom’s cardiologist had received nearly $80,000.
Peggy had a bad feeling about the doctor, and switched her mom to another physician who kept her on the high-priced drug for two months. Then she was diagnosed with anemia, taken off blood thinners and prescribed low-dose aspirin.
In the meantime, Peggy’s husband had a heart attack and developed a blood clot. His doctor prescribed a low-cost blood thinner that’s been on the market for years. She said he’s doing just fine on the “rat poison” disparaged by her mother’s first doctor. His cost: a $6 copay every 30 days.
For a long time, impartial medical experts have thought that the choice of drugs and devices may be related to payments doctors receive from drug and device companies.
Since 2014 the Physician Payments Sunshine Act requires drug and device makers to report to the government the payments they make to doctors. The Medicare database is a treasure trove of some 11 million payments to physicians.
The online publication ProPublica found that drug and device makers gave more than $1 billion to doctors and hospitals from August 2013 through 2016. Some individuals have received payments in the millions.
Peggy said that every time her mom visited the physician, the doctor told her she was lucky to take the expensive blood thinner instead of the other “stuff” which he called “rat poison,” implying a cheaper drug was inferior, even dangerous. Peggy said that at every visit, he said she was fortunate to be taking something better.
Then a family member discovered openpaymentsdata.cms.gov, a database maintained by the Medicare program that reveals the money pharmaceutical companies pay doctors in speaking, research and consulting fees, and for food and drink expenses. Her mom’s cardiologist had received nearly $80,000.
Peggy had a bad feeling about the doctor, and switched her mom to another physician who kept her on the high-priced drug for two months. Then she was diagnosed with anemia, taken off blood thinners and prescribed low-dose aspirin.
In the meantime, Peggy’s husband had a heart attack and developed a blood clot. His doctor prescribed a low-cost blood thinner that’s been on the market for years. She said he’s doing just fine on the “rat poison” disparaged by her mother’s first doctor. His cost: a $6 copay every 30 days.
For a long time, impartial medical experts have thought that the choice of drugs and devices may be related to payments doctors receive from drug and device companies.
Since 2014 the Physician Payments Sunshine Act requires drug and device makers to report to the government the payments they make to doctors. The Medicare database is a treasure trove of some 11 million payments to physicians.
The online publication ProPublica found that drug and device makers gave more than $1 billion to doctors and hospitals from August 2013 through 2016. Some individuals have received payments in the millions.
Still, the drug and device database may be one of health care’s best-kept secrets.
A study published in the British Medical Journal found that only about 3 percent of respondents said they knew their doctor had received payments from the medical industry. Unlike Peggy’s family, they had no idea that Medicare’s Open Payments database existed.
Most Americans don’t readily switch doctors, even in the face of overwhelming evidence that the doctors performed badly. The Lown Institute, a Boston medical think tank, reporting on the British study, concluded, “Maybe we should be more open to switching doctors based on their relationship with industry.”
Peggy had some advice of her own: “Do the research. Did the doctor receive money to push the drug? Ask questions? How much does the drug cost? Is it really a better alternative?”
Do you have an experience about health insurance you’d like to share or a question you’d like to ask? Write to Trudy at trudy.lieberman@gmail.com.
Association health plans have their own pitfalls
By Trudy Lieberman, Rural Health News Service, March 11, 2019
Association health insurance is back!
Perhaps you remember those policies that were offered to you as a member of a local business, social group or trade association. The policies were usually marketed as “affordable” – whatever that meant in those days. Sometimes, though, certain kinds of organizations that offered association insurance became insolvent or engaged in fraudulent activities, leaving policyholders with few options.
When the Patient Protection and Affordable Care Act came along, association policies had to conform to the new Obamacare rules. For one thing, they could no longer consider gender when setting the price of a policy. In the old days insurers could charge women more because they said they were more likely than men to file claims. The ACA also outlawed occupational underwriting: that is, considering a person’s job in deciding to issue a policy.
Last year, however, the Trump administration changed the rules to allow more employer groups and associations, based on common industries or geography, to offer health insurance plans. The goal is to provide a cheaper option than an ACA policy, at least for some people.
According to Kevin Coleman, who has founded associationhealthplans.com to provide facts and figures about the new market, as of earley March, 28 plans were being offered in 13 states. Coleman says if there are 50 in 16 states by the end of the year, he would consider that a successful result.
Time will tell in the next few years whether the updated versions of association health insurance will actually have solved the problems the old ones presented and, indeed, offer policyholders a cheaper option.
Coleman says that so far, plan sponsors claim they typically pay between 23 and 29 percent less to cover those insured than before.
How do sponsors achieve the savings they are claiming?
The new association plans don’t have to offer the same benefits as Obamacare plans. Coleman says he is finding that while many plans do offer mental-health coverage like the ACA policies, they do not cover pediatric dental and vision services that you would find in an ACA plan.
While ACA plans can use only a few of the so-called rating factors like smoking, age, and where a person applying for coverage lives, association plans have much more leeway. They can use occupation in determining whether to insure someone and, ultimately, what a policy costs.
If an insurer doesn’t want to insure rodeo performers, for instance, they can refuse to insure them.
By excluding certain people who are likely to generate lots of claims – like ballet dancers or young women who have babies – the sponsor can save money and, theoretically, pass the savings on to policyholders.
One of the things that Coleman found in his survey is that the deductibles are still very high. As an example, he noted that in one plan deductibles ranged from $4,500 to $10,000 for a family plan and from $1,500 to $5,000 for individual coverage. That’s the amount of medical bills the insured person will have to pay in a year before the insurance even kicks in.
A shopper might expect to find those kinds of deductibles in many of the Affordable Care Act policies and in other individual market insurance as well.
Remember, it’s the interplay among four factors that determines how much your health insurance really costs: the deductible, the amount you pay until insurance kicks in; coinsurance, the percentage of the price of a medical service you pay yourself; the copayment, a flat amount you pay for a service; and the premium. Too often people look only at the premium.
Sellers of the newly fashioned association policies also have more opportunity to charge higher premiums for some people, says Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.
“Promoting easy fixes is creating new winners and losers without addressing the real problem,” Corlette says. “I caution policymakers there’s no magic bullet to affordability. AHPs do nothing to tackle the core problem of hospital costs, doctor and drug costs. The price of health care is too damn high.”
What has been your experience in choosing health insurance for this year? Write to Trudy at trudy.lieberman@gmail.com.
One more chance, until March 31, to look at options for Medicare or Medicare Advantage
A study published in the British Medical Journal found that only about 3 percent of respondents said they knew their doctor had received payments from the medical industry. Unlike Peggy’s family, they had no idea that Medicare’s Open Payments database existed.
Most Americans don’t readily switch doctors, even in the face of overwhelming evidence that the doctors performed badly. The Lown Institute, a Boston medical think tank, reporting on the British study, concluded, “Maybe we should be more open to switching doctors based on their relationship with industry.”
Peggy had some advice of her own: “Do the research. Did the doctor receive money to push the drug? Ask questions? How much does the drug cost? Is it really a better alternative?”
Do you have an experience about health insurance you’d like to share or a question you’d like to ask? Write to Trudy at trudy.lieberman@gmail.com.
Association health plans have their own pitfalls
By Trudy Lieberman, Rural Health News Service, March 11, 2019
Association health insurance is back!
Perhaps you remember those policies that were offered to you as a member of a local business, social group or trade association. The policies were usually marketed as “affordable” – whatever that meant in those days. Sometimes, though, certain kinds of organizations that offered association insurance became insolvent or engaged in fraudulent activities, leaving policyholders with few options.
When the Patient Protection and Affordable Care Act came along, association policies had to conform to the new Obamacare rules. For one thing, they could no longer consider gender when setting the price of a policy. In the old days insurers could charge women more because they said they were more likely than men to file claims. The ACA also outlawed occupational underwriting: that is, considering a person’s job in deciding to issue a policy.
Last year, however, the Trump administration changed the rules to allow more employer groups and associations, based on common industries or geography, to offer health insurance plans. The goal is to provide a cheaper option than an ACA policy, at least for some people.
According to Kevin Coleman, who has founded associationhealthplans.com to provide facts and figures about the new market, as of earley March, 28 plans were being offered in 13 states. Coleman says if there are 50 in 16 states by the end of the year, he would consider that a successful result.
Time will tell in the next few years whether the updated versions of association health insurance will actually have solved the problems the old ones presented and, indeed, offer policyholders a cheaper option.
Coleman says that so far, plan sponsors claim they typically pay between 23 and 29 percent less to cover those insured than before.
How do sponsors achieve the savings they are claiming?
The new association plans don’t have to offer the same benefits as Obamacare plans. Coleman says he is finding that while many plans do offer mental-health coverage like the ACA policies, they do not cover pediatric dental and vision services that you would find in an ACA plan.
While ACA plans can use only a few of the so-called rating factors like smoking, age, and where a person applying for coverage lives, association plans have much more leeway. They can use occupation in determining whether to insure someone and, ultimately, what a policy costs.
If an insurer doesn’t want to insure rodeo performers, for instance, they can refuse to insure them.
By excluding certain people who are likely to generate lots of claims – like ballet dancers or young women who have babies – the sponsor can save money and, theoretically, pass the savings on to policyholders.
One of the things that Coleman found in his survey is that the deductibles are still very high. As an example, he noted that in one plan deductibles ranged from $4,500 to $10,000 for a family plan and from $1,500 to $5,000 for individual coverage. That’s the amount of medical bills the insured person will have to pay in a year before the insurance even kicks in.
A shopper might expect to find those kinds of deductibles in many of the Affordable Care Act policies and in other individual market insurance as well.
Remember, it’s the interplay among four factors that determines how much your health insurance really costs: the deductible, the amount you pay until insurance kicks in; coinsurance, the percentage of the price of a medical service you pay yourself; the copayment, a flat amount you pay for a service; and the premium. Too often people look only at the premium.
Sellers of the newly fashioned association policies also have more opportunity to charge higher premiums for some people, says Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.
“Promoting easy fixes is creating new winners and losers without addressing the real problem,” Corlette says. “I caution policymakers there’s no magic bullet to affordability. AHPs do nothing to tackle the core problem of hospital costs, doctor and drug costs. The price of health care is too damn high.”
What has been your experience in choosing health insurance for this year? Write to Trudy at trudy.lieberman@gmail.com.
One more chance, until March 31, to look at options for Medicare or Medicare Advantage
By Trudy Lieberman, Rural Health News Service, Feb. 24, 2019
Solicitations for Medicare Advantage plans once again have been arriving in the mail, promising the best bargain since sliced bread. A case in point is one from Emblem Health, a managed-care company in my area that says it considers me what they call a “candidate” for their “special needs plan.” I don’t qualify for such a plan.
The solicitation was interesting, though, for what it promised. Free transportation to and from doctor, hospital, and lab appointments, but only up to 24 one-way trips a year. It also promised “no referrals.” Did that mean no referrals were necessary to visit specialists? The solicitation didn’t say.
That seemed highly unusual for what I am assuming is a Medicare Advantage HMO. HMOs usually require consumers to obtain referrals to specialists.
But shoving aside the questionable advertising pitches such solicitations are known for, that one reminded me that beneficiaries are now in a special enrollment period until the end of March. The special enrollment period, which began Jan. 1, gives seniors a three-month window during which they can switch some of their Medicare arrangements.
It’s also a good time for those who will soon be turning 65 to begin thinking of their options and learn what the rules are once they make their selections.
Until the end of March, if you have a Medicare Advantage plan, you are allowed to switch to another Medicare Advantage plan. Or you can drop a Medicare Advantage plan, return to traditional Medicare and buy a Part D stand-alone drug benefit, says Tricia Neuman, a senior vice president of the Kaiser Family Foundation and a Medicare expert.
What you cannot do, if you have traditional Medicare along with a stand-alone drug plan, is switch to a new drug benefit that might let you save more money on your prescriptions. You can do that only during the open enrollment period in the fall.
Keep in mind that if you drop a Medicare Advantage policy and switch to traditional Medicare, you might have trouble buying a Medigap policy to fill in holes in Medicare coverage. Only four states have what’s known as guaranteed issue Medigap insurance. In New York, Connecticut, Maine, and Massachusetts, people dropping Advantage plans in favor of traditional coverage can buy a Medigap even if they have preexisting conditions. In other states they may not be able to do that.
When might it be useful to consider other options during this brief window for switching?
If you have an Advantage plan that has a drug benefit built in as part of the coverage but you believe you can do better with another plan’s drug benefit, then you might want to do the math and see if a switch helps the budget.
Too many consumers fail to do their shopping for the drug benefit when, in fact, they can save thousands of dollars in pharmaceutical expenses by choosing one plan over another.
This special enrollment period gives you a second chance to save on drug costs.
But you may want to switch Medicare Advantage plans or choose traditional coverage, for other reasons that are becoming clearer. Research is beginning to surface that shows Medicare beneficiaries with high medical needs may have trouble accessing care in some Medicare Advantage plans.
Medicare defines those with high needs as people who have three or more chronic diseases and a functional limitation in activities of daily living or in performing routine daily tasks.
The U.S. Office of the Inspector General reported last fall that those with Medicare Advantage plans sometimes had trouble getting claims paid under those plans, or they reported other problems getting help from the plan.
The inspector general said that because so many seniors now have these plans, even low rates of inappropriately denied payments or services could cause “significant problems” for beneficiaries and their medical providers.
Just last month new research reported in JAMA Internal Medicine found that Medicare beneficiaries with high medical needs and those eligible for both Medicare and Medicaid were much more likely to disenroll from Medicare Advantage plans than other beneficiaries.
Researchers at Brown University and Columbia University found that disenrollment from Advantage plans “may indicate that plans do not meet the preferences of enrollees with significant chronic illness.”
This study and the inspector general’s findings offer a cautionary tale for people who will be new to Medicare in the coming months and for sick beneficiaries in Medicare Advantage plans who may want to reevaluate their options during this special open enrollment and next fall when open enrollment comes around again.
What has been your experience in choosing health insurance for this year? Write me at trudy.lieberman@gmail.com.
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