Tag: Rick Gilfillan

Medicare Advantage Has Saved Medicare

Jun 20, 2024

By GEORGE HALVORSON

The Program has also Helped Millions of Low-Income Retirees with Better Retirement Benefits and Needed Support Services

Medicare Advantage (MA) has saved Medicare. Half of those in Medicare are in MA and their care costs less on average. This means the Medicare Trust Fund is protected against future deterioration because MA’s cost increases continuously run below the average increase in Medicare Trust Fund revenue each year.

The capitation paid to MA plans for each member is based each year on the actual average cost of fee-for-service Medicare in every county. Payments to the plans are now running about 11% below that average cost.

The plans bid capitation levels that are below the average cost of fee-for-service Medicare every year because the plans deliver much better care. The functional truth that most policy people do not know or understand is that better care costs less money, when you design the system and the processes to achieve that result.

Fee-for-service Medicare is expensive and too often is poorly delivered. The fee-based payment model pays more for bad and failed care because when the caregivers are paid only by the piece, they have more pieces to deliver when care fails. They deliver and bill for even more pieces when the health of a member deteriorates. When inferior care creates complications and mishaps more pieces of care are needed for that patient.

Diabetic Blindness Reduced By 60% With Blood Sugar Control

MA plans bid capitation levels every year based on the financial opportunity created by that bad care in FFS. The plans know that diabetic blindness can be reduced by 60% or more if the patients have their blood sugar controlled. The plans set their capitation levels knowing that the average cost of care in every county includes the high level of blindness that happens when FFS providers do not help their patients achieve their blood sugar control goals and thus incur extra expenses for those patients.

The Medicare Advantage program has blood sugar control as a key focus point. That is important and relevant, because the plans can collect the capitation money that was created by no blood sugar controls, and then can and do reduce blindness significantly by achieving that goal. They spend significantly less money on those patients.

The MA payment program is set up to have the plans create financial surpluses from better care and then to have the plans use those surpluses to improve the benefits of their members. The plans create those surpluses and use them to pay for additional benefits–so the Medicare Advantage members have vision benefits, dental benefits, hearing benefits, and various social support benefits that do not exist in the traditional Medicare benefit package.

Those expanded benefits do not increase the cost of Medicare because they are created by the capitation cash flow that runs about 11%–17% below the actual average cost for fee-for-service Medicare in each county. That is a far better use of the Medicare dollar and it is not an additional expense for the program.

The plans identify which patients have congestive heart failure or asthma and then they work with those patients to significantly reduce their crisis levels and improve care for those patients. The MA members with those conditions have much better lives and they have less physical pain, stress, anxiety and damage because they avoid those crises. The better care results in 40% fewer days in the hospital for both of those conditions. Plans save money by having significantly better care for those patients.

Amputation Five-Year Mortality Rate is Over 40%

A major expense for the Medicare program is amputations. We have some of the highest amputation rates in the world for our lower income patients.

MA plans know that 90% of amputations are caused by foot ulcers. You can reduce foot ulcers by more than 60% just by having dry feet and clean socks. So the plans save billions of dollars that create surpluses in their capitation cash flow and they significantly improve the life expectancy of those patients just by providing those services consistently and intentionally to their diabetic members.

The five-year mortality rate for the people who have amputations ranges from 40%–80%. In their attacks on the program MA’s critics never mention those amputation numbers and those important and real death rates .

Special Needs Plans Now Serve Over 6 Million People

MA Special Needs Plans (SNP) just had their enrollment grow to 6.5 million members in January of this year. SNP enrollees are eligible for both Medicare coverage and Medicaid coverage. They have some of the highest health care needs in the country and too often have some of the lowest levels of resources to deal with basic aspects of their lives and their care.

The critics also don’t mention that the SNPs do life changing and extremely beneficial work for the lowest-income and highest-need people in the Medicare program.

Millions of people enrolled in SMP plans have been badly impacted by various social determinants of health issues, as well as by care delivery failures for their entire lives. SNPs are often the first organized care related support that millions of those patients have had for their personal care.

People With Weak Retirement Plans Need the Additional Benefits

Those who look at the Medicare program need to understand and appreciate the fact that the expanded benefit package from the plans is often extremely important and directly relevant to the daily lives of millions of people. They are retired but have few assets and low levels of financial support for their retirement years.

We are no longer at the point where retirees in America can rely on a pension plan and basic retirement benefits after they retire. Fewer than half of retirees today have a pension payment or a deferred compensation plan of any kind. Most retirees have a low cash reserves to use to purchase needed services and benefits in their retirement years.

There is a solid set of reasons why almost 90% of our lowest income Medicare beneficiaries are now enrolled in MA plans. There are also obvious reasons why those numbers include more than 70% of African-Americans and more than 80% of Hispanics. Additionally, MA has language competency requirements for Hispanic enrollees that do not exist for fee-for-service Medicare.

Medicare Advantage Is a Superior Program (Part two)

Jan 18, 2022

By GEORGE HALVORSON

Former Kaiser Permanente CEO George Halvorson has written on THCB on and off over the years, most notably with his proposal for Medicare Advantage for All post-COVID. He wrote a piece in Health Affairs last week arguing with the stance of Medicare Advantage of Don Berwick and Rick Gilfillan (Here’s their piece pt1, pt2). Here’s a longer exposition of his argument. We published part one last week so please read that first. This is part two – Matthew Holt

Medicare Advantage is better for the underserved

The African American and Hispanic communities who were particularly hard hit by those conditions and by the Covid death rates have been enrolling in significant numbers in Medicare Advantage plans.

The sets of people who were most damaged by Covid have chosen in disproportional numbers to be Medicare Advantage members. Currently 51 percent of the African Americans on Medicare are in Medicare Advantage plans and more than 60 percent of the Hispanic Medicare members will be on Medicare Advantage this year.

That disproportionate enrollment in Medicare Advantage surprises some people, but it really should not surprise anyone because the Plans have made special, direct, and inclusive efforts to be attractive to people with those sets of care needs and have delivered better care and service than many of the new enrollees have ever had in their lives.

The Medicare Advantage plans have language proficiency support competencies, and language requirements and capabilities that clearly do not exist anywhere for fee-for-service Medicare care sites. A combination of team care, language proficiency, and significantly lower direct health care costs for each member has encouraged that pattern of enrollment as well.

The $1600 savings per person has been a highly relevant factor as more than twice as many of the lowest income Medicare members — people who make less than $30,000 a year — are now enrolled in Medicare Advantage plans.

Medicare Advantage’s critics tend to explicitly avoid discussing those enrollment patterns, and some of the most basic critics actually shamelessly say, with what must be at least unconscious malicious intent in various publications and settings, that the Medicare Advantage demographics for both ethnicity and income levels are a clone for standard Medicare membership. Those critics have said that there is nothing for us to learn or see from any enrollment patterns or care practices based on those sets of issues.

Many people who discuss Medicare Advantage in media and policy settings generally do not focus on or even mention the people in our population who most need Medicare Advantage — the 4 million people who are now enrolled in the Special Needs Plans.

Special Needs Plans for Dual Eligibles

The Special Needs Plans take care of low-income people who have problematic levels of care needs and who very much need better care.

Medicare Advantage Is a Superior Program (Part one)

Jan 10, 2022

By GEORGE HALVORSON

Former Kaiser Permanente CEO George Halvorson has written on THCB on and off over the years, most notably with his proposal for Medicare Advantage for All post-COVID. He wrote a piece in Health Affairs last week arguing with the stance of Medicare Advantage of Don Berwick and Rick Gilfillan (Here’s their piece pt1, pt2). Here’s a longer exposition of his argument. We are publishing part one today with part two coming soon – Matthew Holt

The evidence for Medicare Advantage being a superior program compared to standard fee-for-service Medicare is so overwhelming that anyone who cares about actual Medicare Patients or who cares about the financial future of Medicare should be strongly supporting having as many people as possible enrolled in that program as soon as we can effectively make that happen.

Compared to fee-for-service Medicare, Medicare Advantage has better benefits.

Compared to fee-for-service Medicare, Medicare Advantage has a better tool kit at multiple levels.

Medicare Advantage has team care, connected care, and electronically supported care processes — and we know beyond any debate or dispute that those advantages exist for Medicare Advantage over standard fee-for-service Medicare because fee-for-service Medicare does not pay for those sets of services and literally labels it billing fraud if a caregiver who provides team care in a patients home to prevent a congestive heart failure crisis or to keep a life threatening and function impairing asthma attack from happening sends a bill to standard Medicare for those services.

The superiority of Medicare Advantage is beyond question.

Standard fee-for-service Medicare has no quality care processes, no quality reports and no quality standards or expectations at all. Standard Medicare actually has absolutely no quality data and does not hold any provider accountable for the quality of the care they deliver.

Medicare Advantage has an extensive quality agenda and tracks more than 40 categories of quality and service at the plan level. Medicare Advantage plans build continuously improving programs around those Five-Star priorities and measures, and we know from our current reporting that even during Covid, the percentage of Medicare Advantage patients with cardiovascular disease who are currently on statin therapy went up from 80.86% of patients a year ago to 83.36% this year.

The ratings by the Medicare Advantage members for customer service by their plans went from 90.56% a year ago to 90.87% this year.

That is not a big improvement but having satisfaction numbers that start out that high actually go up during Covid days is an accomplishment and it is one of the reasons why we should be encouraging people to join the plans and its why fee-for-service Medicare is a measurably inferior approach for so many people.

Standard Medicare does not have a clue about who is getting their statin Medications and they officially don’t care.

In fact, some of the fee-for-service Medicare doctors and care sites who are paid only by the piece for care from the standard Medicare program actually often make more money when care fails, because when a patient has a major asthma crisis or a congestive heart failure crisis, that negative outcome for a patient can generate multiple medical fees and it can too often trigger a $10,000–$20,000 total additional cash flow to the caregivers whose care sites failed that patient by not helping improve the health of the patient before the crisis was triggered.

Why is Medicare Advantage’s purchasing system better?

Medicare Advantage plans are paid by Medicare by the month for each patient and they are not by the piece for each item of care.

Because Medicare Advantage plans are paid by the month for each patient, and must, by contract, provide complete care to each patient, it makes extremely good sense for the plans to help patients in ways that prevent asthma attacks and that prevent congestive heart failure crisis, and that avoid and help reduce the levels of blindness and amputations for their diabetic patients that can too easily happen to those patients if you don’t manage and guide that care.

The Medicare Advantage approach for all of those categories of care is obviously far better for the patients than the fee-for-service Medicare inadequacies in care.