Monday Musings

More and more of my patients are on Medicare “advantage” plans. Just this week I asked one of them why she decided to take a Medicare replacement plan rather than a traditional Medicare plan. I was pretty sure I knew the answer because my husband got Medicare this year. Medicare covers only 80% of the medical fees so like many people, we bought another plan to cover the other 20% for which we pay about $230.00 per month.

The cost of this “secondary insurance” is more than many patients over 65 can manage. Patients chose Medicare Advantage plans because they don’t have to purchase those secondary plans—or alternatively, risk being liable for 20% of their medical expenses.

I got invited to a provider meeting for one of the local Advantage plans and I was impressed with several things I heard during the meeting. The primary care physician is notified if one of their patients fails to refill a medication for hypertension or diabetes (for example) and then a central call center contacts each of those patients to discuss their disease management and to make sure they understand why they need their medication. The performance of the primary care physicians is assessed based on their performance of certain PQRS quality measures. In general, there were a number of aspects of the Advantage program that were admirably designed to improve the management of chronic medical conditions like diabetes. However, I asked if I could attend the meeting because I had spent six months trying to get a new CROW walker approved for a patient with a severe Charcot foot deformity. The medical director of the plan had told me that “off-loading was not part of wound care.”

In addition, 100% of my patients with that particular Medicare “advantage” plan have been denied cellular based products for their non-healing diabetic foot ulcers even after I did “peer to peer” phone calls with the medical director of the plan. This particular plan has done a good job of creating protocols for chronic disease management but a poor job in wound care. It seems that they are not certain of the value of either off-loading or advanced therapeutics. That might change based on data from quality measures like the USWR’s “appropriate use of cellular products”. In other words, by submitting data to a Qualified Clinical Data Registry like the USWR, it may be possible to demonstrate the comparative effectiveness of not just cellular products in general, but perhaps even the superiority of one product over another in achieving the best outcome for the lowest total cost.

One comment

  1. Great article, Caroline! I am aggravated almost on a daily basis over patient’s being led to believe they still have traditional Medicare benefits after switching plans. Any other business would be found guilty of predatory practices against the elderly if they pulled even a small percentage of what is going on with these carriers.
    I have been fighting for three months to get one of my patients a knee walker. The hoops he and I have had to jump through have been nothing but time killing delay tactics, in my opinion. His Charcot deformity and non-healing ulcer are a higher level amputation waiting to happen.
    The hubris I have encountered when dealing with some of the medical directors and customer service people is despicable. I posted one other example on my Dr. Desmond Bell Facebook page…I made sure the call to the insurance company on this particular case was recorded….I think I created several new swear words during the call. Can’t wait to vent with you in person. The public needs to wake up…..


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