Medicare Advantage Plans A Failed Experiment?
 

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News

If they discontinue the program then everyone on MA should be allowed into a MediGap program with no underwriting.

Medicare Advantage may be a failed experiment, but so is Traditional Medicare. Medicare fraud is rampant. My mother spent her last 4 months in the hospital or various nursing homes. One medical doctor, who my mother never hired, followed her everywhere she went and billed Medicare for an office visit every day, 7 days per week. She was never hired, and never prescribed any medical treatment. Apparently, she posed as a hospital doctor and got my mother's SSN from her chart. Every day, she would make the rounds visiting her many "patients" in nursing homes and hospitals. Medicare has no checks and balances to determine if a provider was ever even hired by the patient. If they get a bill, they just pay it. At least Medicare Advantage providers have a profit motive to reduce fraud.

The only way to make the system more efficient is to require patients to have "skin in the game" by requiring all patients to pay a copay based on a percentage of the treatment. They need to eliminate free treatments where the patient has no incentive to reduce the cost.

I don't think that Medicare Advantage is correctly labeled an experiment, they have been around for over 25 years. Over 50% of all Medicare enrollees are on Medicare Advantage Plans. Most people say they are happy with their MA plan, at least as many as say they are happy with traditional Medicare.

We are very happy with our advantage plan

it works for me. i've been able to get the care i need, when i need it, for what i want. i've never been denied, never had to sacrifice care. i'm leery of some of these stories, -they appear to be looking for some gut reaction, typically in a sensational way.

Let’s take Aetna (my employer’s Medicare Advantage plan) and I believe only second in Medicare plans to United Health Care the largest. Aetna net income in 2023 was just south of 6 billion dollars. With that much money at stake, the insurance companies are not going away quickly or quietly. CVS Health acquired Aetna for a sum of 69 Billion. Bottom line, instead of regular Medicare paying claims they pay the insurance companies to manage them. Cheaper for taxpayers?

The United Health Care Group revenue was over 189 billion dollar. There are costs but that is a lot of revenue. UHC reported 22 billion in profits in 2023. The CEO of UHC total compensation was 23.5 million. Obviously there is money to be made in health care insurance.

Very happy with UHC Advantage Plan. Have never been denied any treatment needed - and it costs a lot less than a supplement plan.

51% of seniors on MA plans in 2024 - I'll take my chances. Odds or on my side when a change occurs of who the vote getters protect.

Health Insurance companies really depend on Medicare Advantage to drive profits. They make MUCH more from a Medicare member than they do from a fully-insured member.

Medicare advantage plans are very good but the older you get and the sicker you get and the more medical care you need that’s when they’re not good and a lot of things get denied that you would’ve had with original Medicare.

I've never heard of medicare advantage patient being delayed or denied care. I've seen a lot of lives saved through quick emergency response or months of various treatments to fight cancer successfully. Does the OP have an agenda for spreading this 'info'?

I have BCBS Medicare Advantage PPO from MI. It's great. Had it for over 25 years.

Want some proof of denials? Here are a couple but I bet you can find many hundreds of these complaints if you search:

https://www.finance.senate.gov/imo/m...0Advantage.pdf

https://legislature.idaho.gov/wp-con...%20Denials.pdf

By repeatedly denying claims, Medicare Advantage plans threaten rural hospitals and patients, say CEOs

Why does Medicare Advantage routinely deny reimbursements for necessary care? - Quora

Medicare Advantage plans are popular, but some seniors feel trapped when ill : Shots - Health News : NPR

https://crr.bc.edu/criticisms-of-med...ting-continue/

My husband was told there was NO rehab that would accept Humana that could handle a patient on PD Dialysis. I later found that there was a way to make it happen but the discharge planners at Leesburg Hospital instead pushed him out without a plan. FYI 6 months Multiple hospital visits 2 almost immediate discharges at Lessburg and 3 months out having gone to Shands we find he had Pancreatic Cancer, gone under 3 months later. But can you imagine being told there is no place that will take his insurance. Meanwhile no body wanted to recognize that the VA would be paying the bill. It was just no Humana approved place.
BTW there is a BIG difference between a Medicare Advantage HMO & a PPO.

I have an F PLAN with a Part D plan... when you get really sick and your Advantage Plan lets you down, you will regret your choice.., TALK TO A HOSPITAL BILLING ADMINISTRATOR

Yes, it happened to my brother....

LaLamy, yes it's true. A friend who has Medicre Advantage was denied a nuclear test. If they had a traditional they would have been covered, no problem. So, just because you never heard of it, doesn't make your statement true. The advantage plan is good as long as you don't get sick. But, no one knows when you will get sick.....and you will get sick

Absolutely, positively 100% agree. The OP is nonsense, as is the "list" of "denials" a few posts above.

Do insurance companies occasionally deny requests for certain tests, treatments, hospitals or specialists---you bet they do. Advantage plans do, Medicare supplement plans do, private insurance does. ALL insurance plans have a set of policies and approved services. Most denials are simply because the service was not "coded" properly, others because the service might be new or considered experimental. HMOs and PPOs have a panel of approved physicians that are agreed upon by the insured when they choose that plan---it is the patient's decision. You need approval to go "out of network" or undergo a procedure that is not on the approved list. However, even with those restrictions, 99% of the time one phone call from your physician to the medical director of the insurance plan will get you approval. But that request must be medically necessary---whining that you want hospital A or physician B because your cousin's barber liked them won't do, nor should it.

Can one go on the internet and harvest a bunch of medical "horror stories"??? In a country of 330 million, no problem, since those who feel "wronged" are the first and loudest to complain. I can also find legal horror stories, automotive horror stories, daycare horror stories, and ditch digger horror stories. If someone is looking for 100% perfection in any system, might I suggest the planet Utopia?

Do you want to glean populist support? Just claim that the big, bad CEOs are making a fortune by cheating, conniving, deceiving and exploiting their workers, or the taxpayer, or the government. Readers will eat that crap up. The same readers that will pay thousands to see some guys kick a ball around a field or hear some rap crap guy "sing".

I don't know if the OP has an "agenda", but just add my wife and I to the millions that chose an advantage plan and are happy. And as many of you know I am familiar with medical insurance.

Nonsense. Just have the patient sign a doctor's visitation statement.

I've heard of many funky differences. Here's just one:

Our next door neighbor moved in and began pickleball lessons as soon as she landed.

She began practicing and then playing everyday.
Within the 1st months of play, she fell backwards and got very hurt.
Rushed to the E.R., she learned of several breaks to her elbow and needed surgery.
She is on Medicare Advantage.

She had to wait for TEN DAYS before it was approved. She was in excrusiating pain, but was given opioids to aid her.

Everyone was shocked and didn't understand. She and her husband said it was due to their Medicare Advantage Plan.
Glad we're not on that.

Medicare Advantage plans are good until you get really sick. Then you require specialists but the best ones are not in your plan.

Delays and denials are happening frequently. I had a urine test for an infection following surgery. The doctor's office had the ability to do the test immediately in their office. Florida Blue required instead they send the test to another agency. As a result, I went through a weekend of continued agony before we could get the results and prescribe something.

A good friend this year waited FOUR MONTHS to get approval for a CANCER medication.

These two are personally known. You can easily find many, many more.

Not failed. But no real oversight. HCFA (healthcare finance administration), as is most government agencies,is a bureaucratic mess. Just get “someone” in power to clean up these oversight agencies and get people to do the job they are being paid to do. Pay bonuses to employees that report fraud and abuse. Start putting people in jail. If this was another country there would be executions!!!

To the extent that made sense, your urinary infection weekend is on your doctor, not the insurance plan. The proper medical procedure for a presumptive UTI is to treat empirically with antibiotics pending the result of the urine culture. It takes 2 days to grow out a culture, no physicians office is equipped to grow cultures, and if he bothered to have so much as a child's toy microscope he could have looked at the urine sample to determine if excess WBSs were present. Place the blame where it belongs.

As far as "4 months to get chemo drugs" goes, Neither of know, but I suspect that the oncologist chose a treatment protocol or chemotherapeutic agents that fell outside of the mainstream. But like I said above, it's easy to find horror stories. I also suspect the same delay would have occurred with traditional Medicare or private insurance.

Very well said! We're on UHC Advantage and like it.

Yes, there will always be "horror stories" as you pointed out. But MA plans vary, and some are better than others for sure. People need to do the research and make an informed decison.

Having a choice is a good thing, one size does not fit all.
Over 50% of new medicare enrollees chose MA plans. If they were so bad they wouldn't be so popular.

Btw, we really like the wellness and vision benefits. We get free membership to Genesis gym as a side benefit. Very nice place. My wife takes 2 fitness classes a day there 6 days a week.

Please, please, please make ME the "someone" in power as appointed dictator. I'll fix it in under a year. Of course, I'd also have to disband Congress, rewrite some laws, possibly including the constitution, kill all lobbyists and execute those who propagate ridiculous tripe online. Probably not going to happen :1rotfl::1rotfl::1rotfl:

medicare advantage
 

Sounds like sour grapes due to a poor experience? Advantage companies negotiate rates w a small closed group of providers. Trying to go outside the group becomes very expensive. Pick the right plan for providers you want to use.

Our MA plan actually has a very large, nationwide group of providers. Before we signed up we checked here in Indiana. 90% of the hosptals we checked took it. So did the medical group we use.

I mostly agree, but paying bonuses to employees will be wasting even more money. Medicare fraud and abuse are so rampant, that reporting it will do nothing. The people in charge know it exists, but they just don't care. I laugh every time I see a TV ad asking for the public to report Medicare fraud. This is just a publicity stunt to make people think the Government is trying to reduce fraud. If you report it, they already know about it, but they have no way to stop it anyway.

Yes, there are some side benefits as well. The gym I was paying $70/month for is now free. I just got eyeglasses for free.

But the real debate on this thread is access to care and insurance denials. I have Florida Blue MA and even Shands and Moffit are in network. The concept that we are all sacrificing our health to line the pockets of insurance company CEOs is absurd and delusional. Bottom line---most people in America don't want to be "denied" anything, even though they freely chose to save $200/month by choosing an advantage plan. No, these plans are not for everyone----If you already have multiple medical problems with established relationships with specialists who are not in network----skip to traditional Medicare. If you have some rare condition that might require travel to a nationally recognized center, advantage is not for you either. But if you are relatively healthy these plans are just fine, and the chances of developing a condition that would cause you a problem with insurance are quite low---unless you are one of the whiners who specifically want to see the doctor that your barber's cousin in Atlanta likes.

Now, if we're looking for something to bankrupt advantage plans of drive the cost up, consider all the ads for so-called "Medicare advantage dual coverage plans" These are not just health insurance plans. They are for those with both Medicare and Medicaid, and now forgive the $174 /month premium for part B, and pay for "rent, groceries, and utilities". This is nothing more than Robin Hood backdoor welfare on the backs of taxpayers hidden under the guise of "Medicare Advantage"---that's the real deceit, and not by CEOs

Lastly, if you want a "horror" story, my wife's late husband had UHC The Villages Medicare Advantage plan and developed a rare form of myelodysplasia requiring bone marrow transplants that was not on the approved "list of treatments" at the time and could only be done at Moffit, which wasn't in that network. However, with a knowledge of how to navigate the system (she's a nurse with Master's in both nursing and healthcare administration), he got all the treatment he needed at Moffit, but unfortunately was unsuccessful.

These numbers are out of date, about 15 years ago, but at the time Medicare budget was $600 billion/year, fraud was estimated at $8 billion/year and the government was spending $12 billion/year to fight it, without success. If that were a private company and you were CEO, what would you do????

The sad part is that it should have only cost 1% of that to find the frauds----just print out a list of the highest Medicare billers that are not institutions and start there. Number one on the list was a Florida solo cardiologist who billed $55 million in one year. Who thinks that was legitimate?????

Really want to cut healthcare cost? Eliminate the continuing practice of defensive medicine that costs over $1 TRILLION/ year by eliminating runaway jury malpractice verdicts (or killing all the lawyers:1rotfl::1rotfl::1rotfl:)

I have a MA PPO and have been extremely happy. I’ve never had a problem even when I travel.

This is a thread for residents of The Villages, but not one mention of Villages Health.

We have Villages Health and the United HealthCare (UHC) Medicare Advantage Plan. Villages Health only accepts UHC, Florida Blue, and Humana.

The federal government gives a lump sum for each Medicare Advantage subscriber to UHC and other insurance companies.

Villages Health gets a portion of that from UHC, Florida Blue, and Humana. This lets Villages Health build a team of PCP and other staff to service it's members.

Many of the other Medicare Advantage plans DO NOT pass along enough of the federal dollars.

Villages Health selects only certain specialists to service their members, considering their reputation and other factors. Not all specialists qualify to be within the Villages Health network.

We've been a member of Kaiser Permanente HMO for all our adult life before moving to The Villages. We never had any issues being handled within their network. Same has been true being under the Medicare Advantage plan with UHC/Villages Health.

I might suggest that many of the Medicare Advantage problems are with other providers here.

Many retired employees have "free" healthcare from lesser Medicare Advantage providers that Villages Health does not accept. It could be that those companies don't comply with Villages Health expectations or requirements for services and billings.

Your experieces might be different. We are very happy with UHC and Villages Health Their combined network has been excellent for us.

My mother had traditional Medicare, but the system failed badly. She had dementia when she fell and broke her hip. She spent 3 days at the hospital before being transferred to a rehab facility, but she was not officially in the hospital for three days. Medicare refused to pay anything for rehab, and her secondary insurance refused to pay anything because of the decision by Medicare. If ever a patient needed a rehab facility, it was my mother. I was forced to pay out of pocket for a month of rehab, and that would not occur with Medicare Advantage.

We have friends with denials from MA and Private insurance, had to go to medicare.

The typical MA denial is post injury/operation rehab . . . rehab has a long tail of expenses.

I've been inroad to Medicare Advantage for 16 years, works for me

We're on UHC Advantage and like it. I had a compound fracture of my tib and fib, and also broke my ankle in a dirt bike wreck about a year ago. I got great care through the surgery and rehab, and I'm now 100%. After care was very good and everywhere I needed to go here in Indiana took UHC. No denials or pre approval.

We were in TV all winter, and there were plenty of choices for me there as well if I needed anything.
Btw, medicare is not without denials.

This topic was on Next Door and comments from people who are on a Medicare Advantage Plan total disagree with your analysis. I have never been denied procedures, that my doctor prescribe. It's a lot cheaper than standard Medicare, when you have to purchase a supplemental program to cover costs. In addition, I receive money back from my SS assessment for Medicare. Your source sites two experts who disagree on the topic. The source who is positive on Medicare Advantage made more sense and has better arguments to support its' existence.

Reading these threads you have “die hards” supporting traditional Medicare and those that champion Medicare advantage plans. For those under 65, this is a major decision you will have to eventually make. Research is key. Everyone’s personal situation is unique, and one’s health history needs to be taken into consideration. Someone who is very healthy, and goes to the doctor just once a year for their annual checkup will probably rave about how much they love their advantage plan. When it comes to quality health care, cost (though important) should not be the over-riding decision as to which way to go. I personally would want to talk to people well into their 80s, who have multiple health issues going on, who have had multiple hospital stays and rehab, and ask them how their coverage and the plan they selected has worked out for them.