What I Expect From the Medicare Program

What I Expect From the Medicare Program

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After half a lifetime of following the Medicare program, on October 1, 2013, I became a Medicare beneficiary.  I turned 65 on October 31.   I’m part of the leading edge of baby boomers joining the program, ten thousand a day.   We’re going to change this program, both by how we use it and what we expect its keepers in Washington to do to improve it.

Here are some reflections upon joining Medicare.

1-Don’t Refer to Me as “Retired”, Please. I’m still working (hard) and paying Medicare as well as income taxes taxes every month.   Like most of my fellow boomers, I lack the financial cushion I want in order to stop working.  Additionally, for what it’s worth, like all too many boomers, I don’t know how not to work.   So my main goal, which is closely aligned with the country’s,  is to stay healthy enough to keep working long enough to be able to retire comfortably when I wish to do so.

I plan on staying a long way away from the expensive parts of our healthcare system, if only to avoid being inadvertently harmed.  Rest assured that if I know I’m dying, you won’t find me in a hospital if I have any say in the matter.

I don’t consider myself “entitled” to Medicare, or to subsidies from younger people.  I’m paying more than $400 a month in Part B fees and the special assessment on Part D that got tacked on in the Affordable Care Act.   After what I’ve already paid in, that’s not exactly a flaming bargain.  I’ve paid Medicare enough over my working lifetime to buy a  house, and will pay more Medicare taxes for years to come for each month that I work. Nothing makes me angrier than the suggestion that I’m somehow sponging off my kids by participating in Medicare.


2- The Regular Medicare Program is a Relic. There is a lot of political fog enshrouding Medicare.  Personally, I could care less about the politics of this program.  The big choice was fairly cut and dried:  either regular Medicare plus a supplemental plan or Medicare Advantage.   After logging onto Medicare.gov, I found the regular Medicare benefit completely incomprehensible- chopped up into Parts that may have made legislative sense in the 1960’s.  If you included the supplemental coverage,  there were just too many moving parts that didn’t seem to fit together into a unified benefit.

So I chose Medicare Advantage. It’s simple to understand and user-friendly, and looks a lot like my previous coverage.   My doctor is a participating physician as is my beloved community hospital, Martha Jefferson.   And the price is right:  zero dollars after my Part B premium. More than 40% of boomers are picking Medicare Advantage, largely because it’s easy to use and remains a bargain. It will eventually be half the program.

3-  I Want My Doctor to Work for Me. My doctor is the single most important part of the health system. Call me a traditionalist, but I think my doctor’s core obligation is to be honest with me about my medical risks and thoughtful about how I manage them.  I want my doctor to work for me- not the local hospital, or a health plan, or some faceless medical conglomerate. So it makes no sense that his time is worth less to Medicare or any other insurer when he in his own exam room talking to me than it is if he’s a hospital employee talking to me.

Don’t cut secret deals behind my back to change how he cares for me.   And stop wasting his time on meaningless, check-the-box billing and documentation requirements.    He spends half his time on paperwork, in order for him to qualify for “quality” bonuses or to be certified as a “meaningful user” of healthcare IT.   Sadly, a lot of private health plans are even worse than Medicare is.   To all of them, I say: “Stop telling my doctor how to practice medicine.”  If I’m dissatisfied with his responsiveness or the care he provides me, I’ll find someone else.

4- I Still Cannot Get the Information I Need to Make Good Care Decisions. Last year, my father-in-law needed his knee replaced.  After consulting orthopedic surgeon friends about how they’d go about selecting a surgeon, they told me to find out the surgeon’s “re-do” rates for their past knee replacements, and their post-operative infection and complication rates.    None of the hospitals he was looking at could tell me.  When I went online to Medicare’s Hospital Compare, I found 87 (!) well meaning “quality” metrics obviously negotiated with hospitals’ advocates so no-one would look bad. I don’t care about whether the hospital “participates in a systematic data base for nursing sensitive care” or “tracks clinical results between visits” or whether people got their flu vaccine.  I don’t have time for 87 “core” measures.   Just give me the good stuff- the key information that helps me limit my risk.

5-  Treat Me Like a Sentient Grown-Up. When I visited my physician earlier this year, he told me that Medicare was requiring him to hand me, an “elderly” person, patient education materials about my new status as a “senior” as a condition of his getting paid.

When I read it, I learned, among other things, that ”You may notice physical changes such as the graying of the hair, vision changes requiring glasses, decreased hearing, inor iujuries taking longer to heal, decreased muscle strength, slower co-ordination of the reflexes, constipation, etc.”    Thanks for wasting my doctor’s time and for patronizing me.  Medicare, note well:  It’s actually been hard to avoid all the advice about staying healthy.   I’m doing all of it.

When I want your help, I’ll ask for it.

Jeff Goldsmith is president of Health Futures Inc, which specializes in corporate strategic planning and forecasting future health care trends.

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88 Comments on "What I Expect From the Medicare Program"


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archon41
Nov 29, 2013

Here’s what I mean by “balance billing”: One goes to an “out-of-network” provider under a PPO plan, and he accepts what the plan is willing to pay, and then comes after you for the balance of the amount he seeks as his due. Under HMO plans, of course, there is ordinarily no coverage at all available for “out-of-network” service. I appreciate the help, but I’ve been sifting through the options for a couple of weeks now. Trying to get providers to share information about which Medicare Advantage insurers they prefer to deal with is like pulling teeth, but I did get a guarded comment from one that Humana may not be the most prompt in approving referrals and such. The Bro has had no problems with Aetna, which tilted me in that direction. I want a “provider network” to expedite access to providers, when needed. Some years ago, I had a terrible time finding an ortho who would accept Medicare.

Guest
archon41
Nov 29, 2013

Just completed enrollment in the Aetna Medicare Advantage PPO plan (monthly premium $55.) As I indicated above, the “provider network” is very broad (400+ orthopedists in my area.) I did confirm with the “rep” that there are no limits (save the sky) on “balance billing” by “out-of-network” providers. There is an exception for “emergencies,” defined as “life threatening” situations.

Guest
Nov 29, 2013

also the Aetna EOC says the same thing as the Humana EOC concerning balance billing so I suspect we mean different things in using the term balance billing

Guest
archon41
Nov 29, 2013

Ok, just saw the comment you left above at 11:07. If the EOC language, with respect to “balance billing,” is the same in both the Humana and Aetna PPO’s, I suppose I’ve got nothing to worry about. The language does seem broad enough to include both in and “out-of-network” providers. Only thing, when I put the question to the “rep,” she said she would have to ask, and sounded very certain of herself when she returned to the phone.

Guest
Nov 29, 2013

Get a copy of the 2014 Evidence of Coverage document for your plan — which might be specific to your county — on the Aetna web site. It will be in a section about Medical Benefits Chart. (I think it’s always Chapter 4 but not certain.) Don’t wait until it comes in the mail because that typically takes weeks and you only have a week.

Read the rep the language from that section (it’s same as I put in the other comment. with even more detail concerning the three types of doctors I mentioned earlier) Ask her to get a supervisor involved — with you on the line — to make you are completely comfortable with how this works. Just to repeat, the different types of doctors can charge different amounts; they just can’t balance bill. (I would think they also have to take Aetna insurance? That’s another question to ask.)

Do this soon. Up until next Saturday Dec 7 you can change your mind on a Part C plan by simply enrolling in a different Part C plan. (But it looks to me from 2000 miles away and not being a lawyer like if you are otherwise happy with Aetna, your balance billing concern is covered.)

Guest
archon41
Nov 29, 2013

Seems like all the relevant online info is in pdf format, which I can’t download. I’ll get a hard copy of the applicable EOC language, though, and follow up. I see that the Texas Insurance Dept. has a “hotline” for Medicare issues, including Medicare Advantage, and I’ll see what they have to say.

I appreciate your interest.

Guest
Nov 29, 2013

Archon41

Well here’s the good news. You have a week to change your mind and go to the Humana PPO I found for you that does limit balance billing (see back in the thread where we were trading messages earlier). Simply go on medicare.gov or call Humana in the next few days and that will override the Aetna choice.

(Just out of curiosity, why are you choosing a part C plan if you are concerned about networks?)

(Also

Guest
Nov 28, 2013

Mr. Goldsmith’s article includes some interesting statements about Medicare. They got me to thinking (in order of appearance, not importance) and I understand someone else has probably already made these same comments in the comments above:

1. Congratulations to him. The author apparently made and is clearly still making (or at least did in 2011, the year which would determine his Medicare means test in 2013) a lot of money if he has to pay over $400 a month in Part B premiums. But why would he do it that way? Why not just take A? Does Health Futures not offer health insurance? Or is Health Futures just him (in which case, why not structure the business differently?)? Still $400 a month is likely cheaper than what he was paying for insurance bought individually before he turned 65, which must be the way he is looking at it.

2. He says “I plan on staying a long way away from the expensive parts of our healthcare system, if only to avoid being inadvertently harmed.” That’s what everyone hopes but that hope doesn’t help when the drunk driver comes at you the wrong way on I-95. That is why you get insurance.

3. He says “Nothing makes me angrier than the suggestion that I’m somehow sponging off my kids by participating in Medicare.” Couldn’t agree with him more on this one. This was (and happily is still) true of my parents born around 1920 but anyone born after about 1940 like me and the author is paying his or her own way vis a vis Medicare (even when you combine the analysis with SS) no matter what Steurle says

4. The author is right about public Part C Medicare Advantage being a logical choice for many of us baby boomers but it is not for everyone because the prime question should be “Does my doctor take it?” and the next question is “Do I spend most of my time — except for short vacations — in the Part C plan’s service area?” If not, you really have no choice but A/B/D/Medigap/etc. If Ryan and Wyden were better politicians we might have been able to fix the problem with 1965 Medicare that the author identifies (and that no one under 65 understands) but we’ll have to wait another generation now.

5. The zero premium Part C is only a good deal for rich people like the author (or people that absolutely know that they will have no medical bills–loop back to my point 2)

6. His prediction that Part C will “eventually be half the (Medicare) program” leads me to question the author’s expert claim. Because of the PPACA changes, doctors will drop it and or get kicked out of it and the program will wither (loop back to my point 4). I am also a Part A/B/C subscriber though and I’ll take the deal while it lasts (and my doctor takes Part C)

7. As for the free advice on getting old that he got from the Obama administration upon his entry to Medicare, he should not be so critical. The Obama administration has also added pregnancy counseling for us “elderly” too.

Guest
archon41
Nov 21, 2013

Just perused an interesting note in Kaiser Health News: Doctors Complain They Will Be Paid Less by Exchange Plans. Preliminary indications “suggest” that, where a commercial plan pays $100 for an office visit, and Medicare $90, exchange plans will be offering $70 or $60. Matthew Yglesias, in Slate, opines that, since providers are grossly overpaid to begin with, we need not trouble ourselves with their discontent, until we see them decamping to Canada.

Looks like my Medicare Advantage options are limited to Humana, United Healthcare, and Aetna. Anyone have any idea which of these is the most “hassle free” for providers to deal with?

Guest
Jeff Goldsmith
Nov 21, 2013

They won’t decamp to Canada.

Too much trouble.

They will just retire en masse, and leave the hospitals in their markets to pick up the slack with 35 hr a week salaried Gen Y docs, that will cost a lot more (hospitals can bill technical fees for their services, and direct their imaging referrals to the hospital’s imaging department, home to the $3500 MR scan).

Guest
Barry Carol
Nov 21, 2013

It’s good to hear that there are many hospitals around the country that are willing to work with uninsured patients in a fair and responsible manner regarding their bills. I would note, though, that if the charge master price works out to 10 or 20 times Medicare, offering an on the spot 50% discount for cash in the ER isn’t much of a bargain. I’ll offer a simple idea. Require hospitals to prominently post a large sign conspicuously in the ER stating their average charges at charge master rates as a percentage of Medicare. I can see it now. We charge the uninsured and out-of-network insured patients 20 times Medicare rates and we’re a non-profit hospital! But hey, we offer a 50% discount for cash payment at the time of service. 115%-125% of Medicare would be more like it even if you’re wealthy.

Guest
Jeff Goldsmith
Nov 21, 2013

Of course, with Medicare Advantage, the rates charged for “out of network” care are the Medicare DRG/Part B Fee schedule rates. Hospitals are really exposed on the “out of network” rates, including rates for people without insurance. The calls for a new form of hospital rate review basically propose capping the mark-up outside established contracts at some percentage of Medicare, as several of you have suggested.

This is many policy types’ solution to the problem of the “unavoidable” hospital systems- those who have merged to the point where private insurers have to contract with them. Massachusetts will probably be the first state to do something like this. They’ve been talking about it for three years.

Depending on the mark up rate chosen and how broadly applied (e.g. the exceptions policy) , hospital bottom lines could literally vanish overnight. They’ve loaded their entire cash needs onto an extremely narrow segment of the population (e.g. certain privately insured patients who use a lot of extremely high mark up services- imaging, specialty pharmacy, etc.). It’s just hanging out there, and it won’t take many $23 thousand broken legs to move it through balky legislatures. . . .

Guest
Aurthur
Nov 21, 2013

“They’ve loaded their entire cash needs onto an extremely narrow segment of the population (e.g. certain privately insured patients who use a lot of extremely high mark up services- imaging, specialty pharmacy, etc.).”

So let’s destroy the private insured patient insurance companies (the golden goose) and replace it with Medicaid for (almost) all. Then the providers can cost shift Medicaid short payments to the very generous Medicare reimbursement beneficiaries. And, let’s not worry about the half a trillion plus dollars ACA pulled from Medicare. Great plan! I wonder how generous these hospitals will be with all that extra reimbursement they will be getting from Medicare.

Guest
Paul
Nov 21, 2013

It is now just shy of 3/4 trillion over 10 years from a program that will itself need that much more to cover the tidal wave of seniors joining the program over the next decade. It is insane and dishonest for our Democrat politicians to sell ACA as a cost saving to the budget by saying they were going to move that much from Medicare and know that it was impossible. I suppose it is just another lie. Oh, well, what do you expect from this administration!

Guest
Nov 21, 2013

Yo, waiter…
I’ll have what he’s having.

Guest
Barry Carol
Nov 20, 2013

John –

As I’ve said over and over, there needs to be special rules governing how much hospitals can charge for care that must be delivered under emergency conditions. It’s a sad commentary that more state legislatures haven’t addressed this presumably because of the power of the hospital lobby which, by the way, also opposes price and quality transparency.

If I were uninsured and were hit by one of these outlandish hospital bills, I would offer to pay the hospital 115% of Medicare and maybe be prepared to up my offer to as much as 125%. If the hospital refused, I would make the following points:

1. People don’t buy your product because they want to but because they have to.

2.When we sign your form (because we have to) to be financially responsible for the bill, we are implicitly agreeing to pay a REASONABLE amount, not your ludicrous charge master rate.

3.How would you feel if you or a family member of any of your fellow executives were on the receiving end of these bills knowing that the hospital accepts far less from Medicare and private insurers as full payment?

4.If the hospital insisted on charging me vastly more than the Medicare rate, I would threaten to sue them for dealing in bad faith and I would tell them that it’s not just about me but about everyone else facing similar circumstances. Punitive damages might even be in order.

Guest
Paul
Nov 20, 2013

Barry, I couldn’t agree more! Responsible hospitals will usually work with patients and negotiate a fair compromise. I have worked in the nation’s first hospital (Pennsylvania Hospital in Phila) in the credit department, and we did this on a regular basis. My boss always said it was better to have money in hand and was always quite generous with patients in tough times. The hospital had a lot of medicaid and straight charity cases, but his approach actually kept the hospital profitable. My guess is most hospitals would do the same. It is just the bad actors who muddy the water for everyone else, and they are the exception and not the rule. In the end, if negotiation was not in good faith, I would make a take it or leave it fair offer. If not, I would sue them before they had a chance to sue me, but that can be expensive. This issue can arise even if you have insurance, Medicare Advantage included, and get sick out of network.

Guest
Nov 21, 2013

I can verify what you say from personal knowledge, even though this would be called “hearsay” in a courtroom. During my five years working as a food service employee in a large local healthcare system I learned of several specific instances underscoring what you say…

** One of my former employees lost her husband to an agressive brain tumor. But because he had taken an early retirement prior to qualifying for Medicare, and failed to get insurance, his hospital bills were so high that it would have wiped out their lifetime savings and all assets several times over. Guided in part by the hospital’s billing department, his surviving widow was able to transfer all assets to her name — auto title, home, modest bank accounts, etc — after which the hospital “wrote off” the balance of what was due.

** An employee of the accounting department who worked overtime as a dining room assistant with me said part of her job was making calls to collect money owed the hospital. According to her literally millions of dollars was written off regularly after just a few weeks as being “noncollectable.” By the time I heard that I had already learned how inflated the bills were to start with and was not surprised. It seemed to me the “system” (If it can be called that) was to throw a bunch of sh*t against the wall and see what sticks.

** After I qualified for Medicare and no longer needed the hospital’s group insurance I took a job as a non-medical caregiver through an agency. One of my first assignments I met a client’s family member employed by the same hospital in what is called the “indigent clinic,” staffed by hospital doctors, working at no charge on a rotating basis, caring for people in the community who needed medical care but could not afford to go to a doctor.

I presumed she was referring to Medicaid beneficiaries, but she said no, the Medicaid people all went to the main hospital, usually through the ER or some other place. The “indigents” I figured out were a handful of community residents who most likely had too many assets to qualify for Medicaid but were too poor to pay for insurance — very likely older people, perhaps home owners like I was, but unable to find a job offering group insurance — waiting to get old enough to become Medicare eligible.

** And finally, at one of the hospital’s “town hall” meetings for all employees I found myself at a table with other employees I didn’t know. Two of them worked in the ER and I started picking their brains about payments and charges. I discovered that if someone coming to the ER offered to pay cash they got a fifty-percent discount on the spot! When I expressed surprise and said that was amazing, more people need to know about that. .They might collect a lot more money that way because lots of uninsured people go to the ER for non-emergency care, and even many of those who have real emergencies would be more than happy to pay what they could and pay cash on the spot. These employees told me in no uncertain terms that the hospital didn’t want that policy to be widely known because they already had more than they could handle and it would just increase the work load in the ER.

Another commenter up the thread tried to argue that hospitals everywhere are similarly as “generous” and community health care was just wonderful most places in the country, thanks to the generosity of local hospitals. So you are correct, Paul, that most hospitals operate like this on a regular basis, writing off super-high bills and doling out needed care on a “charity” basis.

But I spent my entire working life in food service, managing the working poor. And I can assure you, and anyone paying attention, that the unmet medical needs with which they live and die on a regular basis are far, far greater than most people with insurance ever imagine. For the last ten year of my post-retirement life I have worked in “senior care” environments and have seen what happens to people as they get old and die. Those who have enough money, reasonably good health and family support make it pretty well.

But that population is by no means a large majority, if it is a majority at all. Bernie Sanders’ office put an infographic on Facebook yesterday that says a lot… “The lower people’s income the sicker they live and the sooner they die. Neighborhoods in Boston and Baltimore have a lower life expectancy than Ethiopia and Sudan. Azerbaijan has a higher life expectancy than areas of Chicago. –Dr. Stephen Woolf.”

I’ve said too much so I’ll stop now. I’m just glad to have got this close to the finish line with minimal health care issues. As Bette Davis said, getting old ain’t for sissies.

Guest
Paul
Nov 21, 2013

The reason for the lower life expectancy is mostly due to homicide rates and not medical care, so you have to be careful to dissect out the facts before assuming cause and effect relationships.

Guest
Nov 21, 2013

Right,
Also:
“American men live the longest in Fairfax County, Va. Life expectancy for men in the wealthy Washington, D.C. suburbs is 82 years compared to 64 for men in McDowell County, W. Va., just 350 miles away.”
Prolly lots of gangs and homicides over there in coal country.

I don’t pretend to be any expert. Like Will Rogers, all I know is what I read in the papers…and what I have observed and experienced in my own life. That includes seeing and hearing about the problems of honorable, hard-working poor people by the hundreds, including a couple of apparently healthy young women who died inexplicably early, and were not the victims of homicide. In this post I made reference to both and paid tribute to one of them
http://hootsnewplace.blogspot.com/2013/04/remembering-vickie.html

Guest
Barry Carol
Nov 20, 2013

John –

A shared risk or shared savings contract would be with a specific insurer / payer which could, at least in theory, include Medicare and even Medicaid. So the hospital could have one or more of those contracts with each payer it does business with. Each contract would cover a specific population of patients.

I think hospital licensing of beds is a state level function but I’m not sure. Perhaps another reader could clarify that. Shrinking the number of beds is like an assembly plant eliminating a shift or a large plant idling some of its production capacity. Hospitals are high fixed cost operations. So, if you shrink your capacity by, say, 20% or 25%, that’s fewer rooms that need to be cleaned, fewer patients that need to be fed and cared for, less nursing staff, fewer patients for doctors to treat, etc. You would consider doing this if you were persistently operating well below capacity. In more extreme cases, the entire hospital may need to close.

Guest
Nov 20, 2013

Thanks, both Barry and Paul, for your helpful replies. Physician compensation, like all packages, is and should be more complicated and nuanced than hourly or contract arrangements. There are too many variables to become simple. To coin a phrase, it isn’t rocket science — it’s even more complicated.

This evening I signed up for a Medicare Advantage plan, in effect casting my lot with the private sector from here into the future. Returning to original Medicare would not be feasible without a supplemental policy to cover what CMS doesn’t reimburse for hospital or physician services. And once you have gone with the private sector, the only way to change plans is to face medical underwriting, which is a polite way of saying that the more problems you may have had, the more you will be expected to pay.

Within hours of my decision ABC aired yet another feature shining a light on the horrendous charges some hospitals use to inflate their bills. And the example in the report was none other than the one almost within walking distance of where I live! Once again I checked the MA materials to confirm that my annual out-of-pocket cap will be less than five grand — worst case scenario. Whew!
~~~~~~~~~~~~~~
Postscript: Four years ago there were no MA plans available where I live, and now, three years later, four or five companies are offering them, HMO and PPO, plus Kaiser, the tightest of them all (but which seems to have the highest satisfaction ratings from customers).

Guest
Paul
Nov 20, 2013

You are correct that bed licensing is usually a state function. Hospitals often will close a unit or floor in times of very low census and open them when demand occurs, especially in the winter months. For that they need no governmental permission. They have to be prepared for their maximum need, which will at times exceed 100% capacity. Any hospital having a high population of medicaid usually has some very serious financial problems because of below cost reimbursements, and medicaid rates loom ahead for a large number of ACA patients. The expectation is that many hospitals, particularly in poor rural areas will be closing. In California, with their high illegal immigrant population, some hospitals have closed in the recent past. So, it is possible to have an increased demand in the near future with fewer resources to meet those demands. Hospitals negotiate individual contracts with each insurance company.