OP-ED

What I Expect From the Medicare Program

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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archon41
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archon41

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… Read more »

archon41
Guest
archon41

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.

Dennis Byron
Guest

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

Dennis Byron
Guest

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

archon41
Guest
archon41

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.

Dennis Byron
Guest

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… Read more »

archon41
Guest
archon41

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.

Dennis Byron
Guest

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… Read more »

archon41
Guest
archon41

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… Read more »

Jeff Goldsmith
Guest
Jeff Goldsmith

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).

Barry Carol
Guest
Barry Carol

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… Read more »

John Ballard
Guest

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

Jeff Goldsmith
Guest
Jeff Goldsmith

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… Read more »

Aurthur
Guest
Aurthur

“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… Read more »

Paul
Guest
Paul

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!

Barry Carol
Guest
Barry Carol

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,… Read more »

Paul
Guest
Paul

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… Read more »

John Ballard
Guest

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… Read more »

Paul
Guest
Paul

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.

John Ballard
Guest

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… Read more »

Barry Carol
Guest
Barry Carol

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… Read more »

Paul
Guest
Paul

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… Read more »

John Ballard
Guest

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… Read more »