Go Ask Alice

One of the ways I test my students’ working knowledge of Medicare eligibility is by having them engage in a Medicare insurance counseling simulation. This is no easy undertaking.  Medicare’s “layer cake” approach (one layer for in-patient benefits, one layer for out-patient services, a third layer for prescription drugs, a fourth for Medicare Supplemental Insurance (popularly known as “Medigap”))  makes for a complicated, fact intensive approach to insurance counseling. Of course, that is part of the lesson.  Are America’s seniors well equipped to choose, choose, and choose again on each layer of the cake?  Is the Medicare layer cake a splendid edifice to insurance design or a horse designed by a committee?

The second biggest takeaway from the Medicare counseling simulation is that original Medicare is a relatively thin benefit.  The fact that the vast majority of  Medicare beneficiaries supplement with some type of Medigap plan (employer sponsored or sold by commercial insurers in a structured marketplace with a wide variety of price points) does not mean the original benefit is not thin.  At the very end of the financial continuum, Medicare beneficiaries who have very low income and assets may qualify for Medicaid simultaneously, making Medicaid a kind of Medigap for them.  This is what it means to be “dually eligible."

What about the seniors too well off to be dual eligibles but too low income to be able to afford Medigap?  They gravitate to enrollment in Medicare Managed Care.

The way I see it, if you understand that Medicare Advantage (Medicare Managed Care or Medicare Part C) may require that you trade in  your traditional Medicare (Medicare fee for service) poker chips for a Medicare managed care plan poker chip that serves to insulate you from original Medicare’s thinness,  you are not only learning something about how Medicare works, you are also learning something about how we ration care.  Under Medicare Managed Care – as with all managed care – we hide the hand of rationing by saying the insurance company is engaging in utilization review.  Of course they are, but the explicit purpose of managed care is both to lower cost and improve quality. These goals remain constant in the Medicare form of managed care, the plan of last resort for the  those too poor for Medigap but too rich to be dual eligibles.  And so we ration Medicare unevenly.

So, who is Alice?   Alice is my own insurance counseling non-simulation.

Alice is a friend – a remarkably robust and lively octogenarian  -- who contacted me around Christmas to let me know that she had fallen outside her home, broken her hip, had surgery, and was now in rehab for her Medicare  sanctioned 21 day stay.  Her next missive let me know that, during Medicare’s open enrollment this past fall, financial exigencies had pressed her to abandon fee for service Medicare for a Medicare Managed Care plan.  And, you guessed it, the Medicare Managed Care plan kicked in mid-treatment on January 1, 2013.

Health insurance policies sometimes make provisions for the continuation of care of procedurally based medicine (but not so much chronic care treatment) that straddles enrollment in two different health insurance plans. Not so Alice’s new plan.

Alice is in no-woman’s land. Disenrolled from fee for service Medicare – and unable to keep the surgical follow-up appointment from a surgeon who takes Medicare assignment but does not participate in Medicare Managed Care – and moved to a Medicare Managed Care rehab funded facility, Alice was advised that this was her problem to unravel. Her new Medicare Managed Care insurance plan vacillated between advising her she was not an enrollee in their plan and advising that, even were she an enrollee, no follow up post-surgical appointment was necessary.

Alice, a wise women, approached me to ask if the best way out of the mess was to charge forward with her new Medicare Managed Care plan or to use the 45 day cancellation option of  Medicare Managed Care and regroup in Medicare fee for service for a few months.

Although the thought of Alice having to argue with her new insurance company from the comparative disadvantage of her painful position made me uneasy, I wondered if cancellation made any sense.  Alice has had to sort through whether she could afford traditional Medicare’s costs for her hip fracture in a system with precious little price transparency. She has had to guess at her anticipated exposure. The  projected answer: without a Medigap policy, she probably cannot afford to regroup in traditional Medicare for another few months.

So Medicare Managed Care it is, if she can persuade them she is an enrollee.  Of course, she can always appeal the decision to deny services and put together the records for an appeal -- from her rehab bed.

Bear in mind that Medicare is that portion of our health care system that ranks highest in patient satisfaction data.

Or, you can go ask Alice.

x posted at http://prawfsblawg.blogs.com/

Comments

[Dennis]

The author is clearly from the academic tradition that cannot distinguish health care from healthcare insurance.

Although the author is the only person I have ever heard use the term "Medicare Managed Care," the author does not seem to be using the word "managed" in the sense Medicare might use it if it ever uses it (see next paragraph). The point of most Part C plans is that a primary doctor "manages" your health care needs. The word "managed" is not used anywhere that Medicare might use it if it ever uses it (again see next paragraph) in the sense of rationing by an insurance company.

Furthermore -- and I repeat this term "Medicare Managed Care" appears to be a figment of the blog author's imagination -- I don't even see the word "managed" without the other two words used at all in the primary Medicare documentation on this subject although it might be in the fine print of pages 74-75 of "Medicare and You, 2013" somewhere. But managed care for non-seniors in the sense I am using the word "managed" is the linchpin of the 2010 Patient Protection and Affordable Care Act. Everyone better learn to love it.

Specific to Alice, we have to assume what the author of this post means is that sometime between October 15, 2012 and December 7, 2012 Alice chose to join an HMO-type (networked, coordinated, accountable care using so-called global or capitated payments) Part C Medicare health plan effective January 1, 2013 as opposed to
-- choosing a Part C Medicare PPO or FFS or HMOPOS or SNP or Medicare Cost or HSA health plan, none of which have the same extent of physician "management" or networking requirements as an HMO-type Part C Medicare health plan
-- staying with whatever Alice's 2012 status quo Part A/B situation was, which may or may not have involved a former employer's retiree plan and/or a Medigap plan and/or a Part D plan (but apparently did not include a Medicare Savings Plan or LIS)

And we cannot even begin to guess why Alice did this but any scenario I can think of is not instructive one way or the other of "managed care," under Medicare, Obamacare or any other health care insurance policy. And, if Alice was with it (as the author strongly implies), it definitely does not support the author's attack on Part C insurance companies (what is that whole "they don't think she is a subscriber" thing about?).

It appears that the whole whine by this author revolves around the fact that the surgeon that operated on Alice in December is not in the network of the HMO Alice joined in January. This is the least of Alice's issues:
-- Specifically, the rehab benefits under Original Medicare and Part C are exactly the same by law. (But Alice might have had a Medigap policy in 2012 that provided better rehab coverage than Part C and Original Medicare provide but we do not know that from the background provided by the author because the author's apparent intention is simply to deride Medicare Part C, not to help Alice.)
-- The regular post-op visit to the surgeon might actually be included in the fee charged in December.
-- If more extensive follow-up and further surgical intervention is needed than Alice has to go to someone in the network. Presumably if Alice is robust and lively, she knew this when she chose an HMO (given the description in the blog, it's not like she had a favorite orthopedic guy or gal and then -- my god -- found out he or she didn't take the Part C plan). Hopefully Alice chose a network that included her regular doctors
-- How much money did Alice really save? Depends on where she lives; the author does not tell us.
-- Depending on where she lives, Alice might not be able to get back into a Medigap policy without some waiting period if she uses the Part C disenrollment option between now and February 14

[Ann Marie Marciarille]

Medicare Managed Care Manual: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c01.pdf

[Dennis]

Thank you. Looking at this document (that no Medicare beneficiary like me or Alice would ever see), it appears that -- as I said -- when the Medicare bureaucracy uses the term "managed," it means "coordinated" (by a primary care physician), not rationed. In fact, it appears that in January 2011, the Medicare bureaucracy specifically changed the word "managed" to "coordinated" in the text but apparently did not want to change the name of the document itself. And more important, as I said, in the documentation we seniors receive the word "managed" with or without "care" does not seem to ever appear.