by Tim Rowan, Editor Emeritus

O

ne just does not know whom to believe anymore. This week, we were sent three opinions of the pros and cons of Medicare Advantage programs. One says they reduce costs and improve patient satisfaction for rural residents. Another says rural hospitals are turning away MA customers at a growing rate. The third says MA customers utilize healthcare services at a lower rate than traditional Medicare beneficiaries. Let’s take a look at each opinion.

Better Medicare Alliance is a non-profit advocacy group that promotes Medicare Advantage. They describe themselves and the genesis of their recent report this way:

“Better Medicare Alliance engaged ATI Advisory to understand Medicare beneficiaries who live in rural areas and how they are served across Medicare Advantage and Fee-for-Service (FFS) Medicare. Understanding geographic differences in beneficiary experiences is important to both the Medicare Advantage and FFS Medicare program. This research can help policymakers and stakeholders identify opportunities to improve access to and quality of rural health care.”

That sounds good so far. Let’s look at their conclusions.

• • 30 percent fewer MA client live in rural areas compared to cities and suburbs
  • rural MA enrollees are more likely to be Black or LatinX but health needs are consistent across all rural demographics
  • satisfaction is the same between rural MA clients and traditional Medicare beneficiaries, though MA enrollees use preventive services more and outpatient services less
  • rural MA enrollees spend less in premiums and out of pocket costs than traditional Medicare beneficiaries

There was evidence last fall that Medicare Advantage was under attack when several hospitals announced they were reviewing their arrangements with Advantage plan sellers and were not accepting some or all plans. The CEO of the Brookings Hospital system in Brookings, South Dakota, told me, “The difference between original Medicare and Medicare Advantage is vast. Advantage plans pay less, don’t follow medical policy, coverage, billing, and payment rules and procedures, and they are always trying to figure out how to deny payment for services.”

In 2023, Becker’s Hospital Review began reporting on hospitals that were dropping some or all of their contracts with Advantage plans. The August 20, 2024 update indicates 18 more hospitals have or will drop MA plans this year. 

Ms. Lieberman went on to report that MA plans frequently limit in-plan physicians. When they eliminate a physician in a rural community, patients often must travel miles to reach an approved doctor.

“Another damning report, this one issued by the Nebraska Rural Health Association, also revealed the pitfalls of joining an Advantage plan. The report warned that Nebraskans with Advantage plans ‘have created such a financial burden for rural residents’ that when they get sick, those with Medicare Advantage coverage ‘represent the largest growing segment of charity care for Nebraska’s rural hospitals.’ I’d bet few if any seniors are told they may end up on charity care if they choose an Advantage plan.”

A hospital in 23,000-resident North Platte, Nebraska has stopped accepting all MA patients. CEO Ivan Mitchell told Ms. Lieberman that transfers to nursing home and Home Health are denied 13 percent of the time. “Hospital stays are 40 percent longer for MA patients. They are stuck in the hospital two or three days waiting for approval to be transferred, and we need those beds for sicker patients.”

The Research Institute for Home Care awarded a grant to Tami M. Videon, PhD, and Robert J. Rosati, PhD, of the VNA Health Group, the honored Home Health not-for-profit in New Jersey. The researchers divided beneficiaries into three groups: Traditional Medicare, MA with a premium, and MA without a premium. Their findings resonated with the experiences of rural hospitals more than those of the MA advocacy group.

• • Traditional Medicare (TM) beneficiaries were more likely to utilize outpatient, inpatient, and home health care services than beneficiaries in Medicare Advantage (MA) plans, regardless of whether the plan had a monthly premium or not.
  • Beneficiaries who reported being in zero premium MA plans were substantially less likely to use dental, hearing, and vision services compared to other beneficiaries.
  • Rates of utilization of hearing and dental services were relatively similar for beneficiaries reporting they were in MA plans with a premium and those enrolled in TM. Access to vision services was greatest among beneficiaries reporting being in MA plans with a premium.

In their research briefing, the researchers stated:

“Consistent with the literature, this study found beneficiaries enrolled in MA  plans had lower utilization for services required to be covered by Medicare (outpatient visits, inpatient admission, and home health care use) than beneficiaries enrolled in TM. The observed lower rate of home health care utilization among MA beneficiaries may result from restrictions in inpatient care. However, prior research indicates when analyses are restricted to similar patient populations (a subset of diagnostic codes), MA beneficiaries are less likely to receive home health care than TM beneficiaries.”

We have often reported on the lawsuits that various federal departments have lodged against the largest health insurance companies for their Medicare Advantage practices.  With their payments from the Medicare Trust Fund based on patient assessments, they have been caught exaggerating illnesses, adding chronic conditions that do not exist, and conducting periodic home visits to “update” their data on the health condition of their customers. These nurse visits to the home frequently “identify” serious health conditions that the person did not know they had, or in most cases did not have at all.

As a consequence of this practice, coupled with denying care that Traditional Medicare would have covered, the program has been determined by government audits to cost 119 percent of what Traditional Medicare costs. 

Should Home Health follow the lead of so many rural hospitals and begin to Just Say No? Our guess is that this will be a prominent topic at this October’s NAHC Conference in Tampa.

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