Should Doctors Warn Patients About the Downsides of Medicare Advantage Plans?

Beneficiaries may not be aware of the plans’ limited networks or prior authorization rules

https://www.medpagetoday.com/special-reports/exclusives/102143

Many doctors tell variations of this same frustrating story after every new year. A long-time patient shows up for a routine scheduled appointment with “great news.”

“Doc, I heard this terrific TV ad — even had Star Trek’s Captain Kirk — about a better Medicare plan for me. So I called the number on the screen and an agent signed me up. He said I would save tons of money! So I dropped my drug and supplemental plans, and now my prescriptions, eyeglasses, and hearing aids will all be covered!”

The doctor groans to himself. This patient doesn’t realize it, but he is no longer in Medicare. He has been enrolled in a commercial Medicare Advantage (MA) plan run by a private company with a provider network to which his long-time doctor does not belong. Or the doctor is contracted with the plan and in-network, but his practice is at capacity so he’s not accepting new enrollees. Or the waiting list is long.

Doctors are left with a choice: send the patient home without care, ask the patient for payment, or be prepared to give the service for free. “It’s very common for patients to come to my office thinking they still have Medicare when they’ve actually signed up with a Medicare Advantage plan and don’t understand that they have given away their rights to that card,” said James Grisolia, MD, a San Diego neurologist.

Doctors, especially specialists, said they have concerns about how exaggerated claims on TV ads and other marketing material mislead patients into thinking they can continue to see any doctor they had been seeing prior to their switch.

No Prior Authorization

If the doctor is not in that plan network, “they have absolutely no insurance coverage when they arrive,” Grisolia said. But even if the doctor is in the MA plan’s network, the MA plan required that the visit receive prior authorization, which wasn’t obtained.

This troublesome issue occurs more often these days as an increasing percentage of Medicare-eligible patients — now roughly 48% of 58 million beneficiaries — are enrolled in Medicare Advantage plans. Some doctors think they should go out of their way to alert their naïve patients to the downsides of these plans before they change their coverage.

“We definitely have patients who join one of these plans and then ask us afterwards about it, when it’s too late” because the enrollment deadline has passed, said David Podwall, MD, a New York neurologist who is president of the Nassau County Medical Society. “We tell them we’re not in their new plan. They have to seek new doctors.”

Texas Medical Association President Gary Floyd, MD, said that doctors in his state do reach out. They distribute information sheets listing the pros and cons. “But it’s my impression that even if the [patients] look at that, they tend to get sucked into buying the plan with the cheaper premium.”

The TV ads, he said, are “almost false advertising, because they make the plans sound like the best thing since sliced bread, that a retired person doesn’t have to pay anything. That’s great for outpatient visits when they go once or twice a year, but when they get sick and go into the hospital, they realize they don’t have coverage for that.” Generally, said Floyd, most of the doctors who take care of adults tell them that “if and when you go on Medicare, stick with the plain, regular Medicare system. Don’t take Medicare Advantage because it’s not going to give you the coverage you need if you get sick and have to be in the hospital.”

Talk With Patients

But how aggressively should the physician pursue the issue with a Medicare-eligible patient? Joan Teno, MD, an internal medicine geriatrician and researcher at Brown University in Providence, Rhode Island, has serious concerns about the power health plans have to drop doctors from their networks with a mere 30-day notice. For that reason, among many others, she believes doctors do have an ethical obligation to warn their patients, even if the patients don’t initiate the conversation.

Additionally, beneficiaries have no way to compare the quality of the plans. “Consumers want to know which plans seem to be overly aggressive in their denials and their limits on access,” she said. How often does the plan reject beneficial treatment? “This information is just not available to make a decision … Maybe the way consumers should think about this is to avoid MA plans at all costs,” she said.

Dirty Little Secret

Complicating the issue is that once enrolled in a Medicare Advantage plan for 12 months, it can be impossible to return to traditional Medicare without incurring enormous deductibles and co-pays of 20%. In addition, Medicare supplemental policies — also called Medigap plans — that pay those costs for the beneficiary can reject an applicant through underwriting questions on the basis of common pre-existing conditions. Only Maine, Massachusetts, New York, and Connecticut prohibit Medigap underwriting.

Gail Anderson, MD, a Bowie, Maryland otolaryngologist who retired earlier this year, said she knew nothing about Medicare choices while she was practicing. The office took care of all that. Now 69, she was faced with a “shock” at how difficult it was to differentiate. “We weren’t taught anything about this in medical school,” she said. And if she, a physician, had difficulty, “how can the average person understand what to do?” she asked.

She finally turned to her hospital’s former CEO, a long-time friend. “Look Gail, you don’t want a Medicare Advantage plan,” he told her. Anderson added that “he told me that with MA plans, I’d be limited to a network of doctors and you don’t get covered when you travel.”

Many physicians interviewed acknowledged that they don’t have the time to discuss the issue, nor do they really know the differences between so many Medicare plans — that it’s too complicated or “not in their lane.” And besides, they don’t have that kind of time during an office visit.

Brokers, Anderson acknowledged, may have a conflict of interest because they earn hefty commissions for selling MA plans. But she learned of a resource she didn’t know about before to whom doctors can refer their patients. The federally supported State Health Insurance Assistance Program has offices in each state specifically set up to provide seniors with unbiased, truthful guidance.

The Need for an Accurate MA Doctor Directory

Doctors feel so strongly about problems with Medicare Advantage network adequacy that during the interim American Medical Association meeting last month, members approved a resolution calling for “Uniformity and Enforcement of Medicare Advantage Plans and Regulations.”

The resolution authorizes the AMA to urge the Centers for Medicare & Medicaid Services to publish an “accurate, up-to-date list of physicians” in each plan network, and to specify whether each doctor is taking new patients. When physicians stop taking new enrollees, they would notify the directory.

“We know doctors move in and out of these plans on a daily basis,” said Jenny Boyer, MD, an Oklahoma psychiatrist who proposed the AMA resolution, which also asks for CMS to be more aggressive in holding the plans accountable for abiding by CMS standards regarding network adequacy.

Can You Still See Me?

Ted Mazer, MD, a recently retired California otolaryngologist who will soon turn 65, thinks physicians should talk with their patients about the upsides and downsides of Medicare Advantage plans — including their limited networks — compared to standard Medicare, especially if they’re about to become eligible. “Doctors can bring up the topic by saying something like, ‘by the way, you’re going to be on Medicare in a few months. Do you know which Medicare program you’re going to so we can discuss whether you can continue your care here?’ That’s advocating for the patients’ access, so why the heck not?” he said.

“They might say to their patient, ‘here’s something you need to know: If I try to refer you to a specialist, I may have a problem. So if you want Medicare Advantage, you should first check whether all the specialists that you might need to see are in your network and accepting new patients,'” he said.

Of course no patient can know what her future medical needs will be, and thus won’t always know which doctors she should check. And even if the provider is in the network, he or she may not be the following year, and the patient will have to find someone else.

NYU Langone bioethicist Arthur Caplan, PhD, said that not only can doctors talk with their patients, they should. “Doctors have a duty to inform patients to the extent they know about the upsides and downsides of Medicare Advantage, especially if their older patients are getting heavy pressure from home care and other companies to sign up.”

And if the doctors don’t know, “they ought to direct patients to elder law attorneys, whether the patients ask or not. And it’s especially true if the patient is overwhelmed and needs family or friends’ involvement. Preventing fiscal toxicity and loss of access is an important, admirable, and virtuous thing to do if providers can do so.”

Filed under: General Problems