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I really don't know much about Medicare so I decided to visit the wikipedia page on this. Here is how it describes Medicare Advantage: > Medicare Advantage (Me

by jack_h 3y ago

I really don't know much about Medicare so I decided to visit the wikipedia page on this. Here is how it describes Medicare Advantage: > Medicare Advantage (Medicare Part C, MA) is a capitated program for providing Medicare benefits in the United States. Under Part C, Medicare pays a sponsor a fixed payment. The sponsor then pays for the health care expenses of enrollees. Sponsors are allowed to vary the benefits from those provided by Medicare's Parts A and B as long as they provide the actuarial equivalent of those programs. > Plans must be approved by the Centers for Medicare and Medicaid Services (CMS). If a MA plan changes some benefits, the savings must be passed along to consumers by lowering co-payments for doctor visits (or any other plus or minus aggregation approved by CMS).[2] Coverage must include inpatient hospital (Part A) and outpatient (Part B) services. > Original Medicare and Medicare Advantage pay healthcare providers differently. Original Medicare typically reimburses healthcare providers with a fee for each service.[5] This fee is often calculated with a standard formula (for example, the prospective payment system for hospital services). Providers either accept Medicare's reimbursement rates or opt out of the program.[5] Public Medicare Advantage plans negotiate payment rates and form networks with healthcare providers, similar to private health insurance plans that almost all Americans not of Medicare age use. Is it that last part that turns this into the "free market"? My lay reading of just the wikipedia page doesn't give me the impression that any part of this is subject to free market forces. What am I missing?

borski 3y ago
Yes, it’s the last part. Medicare has set prices it will pay [0], period, and Medicare is not prone to denying procedures that a physician thinks is necessary. This is a public socialized good. MA plans negotiate with providers, similar to a regular commercial insurance company, for different “deals.” As you may be aware from commercial insurance, that typically means higher rates, since everyone along the line has to get paid across the providers and the insurance companies. Much higher profit motive than a socialized good. On top of that, MA plans have an incentive to deny coverage wherever possible, because as a for-profit entity they want to make as much money as possible, not get old people healthier. Young people have trouble fighting insurers on denials. I know this firsthand. But it’s doable, because we tend to have more energy and less cognitive impairment; I’m generalizing here, but dementia is a thing that happens to a lot of people in old age, for example. For older people, fighting insurance companies is just about impossible. Often, this falls on their younger family members to help (ask me how I know, lol), but that implies their family or friends are willing to help. Not everyone has that. And it shouldn’t be that way. [0] There is a thing called Excess Charges that providers can charge, if they don’t accept the Medicare fee table, but still accept Medicare generally. They have to tell you before the service, or you are not responsible. It is also capped at 15% of the service, and is illegal in some states entirely, and capped lower in others. Some Medigap plans also cover excess charges, but they are on the more expensive end.
- pdonis 3y ago
  "Profit motive" is not the same as "free market". In a free market in health care, the only way to make profits would be to provide genuine services that are of value to the patients who are paying for them. In our actual system, lots of profits can be made by specializing in working the system that has been put in place by the government, to the detriment of patients. I totally agree that it shouldn't be this way. I just don't agree that the way to fix it is more socialized control by the government.
  - Tagbert 3y ago
    A free market involves choices, information, and the ability to change choices based on that information. With health insurance the choices may be limited, you have very little information about what things cost and whether insurance will cover a given procedure. Most people are not educated well enough to be able to properly evaluate their options. You are only able to change your choice once a year. This is a free market in name only. But the impact of choosing incorrectly is very expensive.
  - borski 3y ago
    The US government did not invent insurance. If a company wanted to compete with an existing insurance company but do it differently, they can already do that; direct primary care offerings exist right now. Healthcare, when coupled with a profit motive, offers misaligned incentives, period. Getting people healthier for cheaper doesn't make a healthcare company money. That is why I believe basic healthcare should be socialized. That doesn't mean we can't have private companies offering countless other medical services or additional insurance, but nobody should be getting denied a cochlear implant because they are deaf due to 'paperwork issues' for months or years until they die.
    - pdonis 3y ago
      > The US government did not invent insurance. I never claimed it did. My claim is that what we call "health insurance" in the US is not just insurance; it is a bundle of insurance (coverage for high cost unforeseen events) with other things that aren't insurance, but have to be bundled with it because the government says so. > direct primary care offerings exist right now. Yes, they do, but they are hamstrung by the fact that the US health care system disincentivizes patients from using them. If all primary care in the US was provided by such places, and patients paid the costs directly, that would be a free market, at least in primary care. But that's nothing like what we have. It's certainly nothing like what Medicare Advantage, which is the subject of this discussion, provides. > Healthcare, when coupled with a profit motive, offers misaligned incentives, period. Not in a free market. Health care in the US before WW II was provided by private companies (or individuals like doctors with their own practices), for profit, and worked better, given the technology of the time, than what we have now. What ended that system was laws passed during WW II that fixed wages, which meant that companies could not compete for labor in a free market by offering higher wages. So companies looked around for other benefits they could offer to compete, and health care was an obvious one. And then after the war the government decided to regulate the company-provided health care instead of ending it and restoring a free market. What offers misaligned incentives is the bastardized system we have in the US, which combines the worst features of for-profit with the worst features of socialism. The for-profit part is not visible to the actual patients--as I have already pointed out upthread, patients have no idea what the services they are getting actually cost, so they have no idea whether they are worth what they cost. The socialized part is what patients see--the services available to them are determined by their health "insurance", not them--but decisions are made by third parties who have no skin in the game and suffer no consequences when they make bad decisions that cause harm to patients. > nobody should be getting denied a cochlear implant because they are deaf due to 'paperwork issues' for months or years until they die. Of course not. And this would not happen in a free market. It happens because we don't have a free market in cochlear implants, we have a non-free market system with misaligned incentives, as I described above.
IG_Semmelweiss 3y ago
Its not free market but its technically more choice. Basically its taking a subsidy (Medicare funding") and offering it to 3rd parties willing to offer equal value, but shuffled around so the benefits are "chosen" by patients who know what's best for them. Here is the secret: in almost all cases, regular medicare is better for most patients. You may pay more upfront (coins, copay) but there are fewer surprises.
- borski 3y ago
  If they incentivize every insurance company the same way, and in the same amount, it is still a free market. The playing field is still level.
- CalChris 3y ago
  Traditional Medicare pays most but not all of covered health care costs. So to cover the gap in coverage there are private standardized Medigap plans. Plan G has no copays, coinsurance or deductibles except for the Part B deductible ($240/yr). Love Plan G. I would argue that Traditional Medicare has much more choice; most doctors+hospitals and all ERs accept Medicare Assignment. You can also go to the Mayo Clinic, Cleveland or Cedars Sinai with TM but rarely with MA.
  - tpmoney 3y ago
    Doesn’t plan G have something like a 300-400 monthly premium on top of your $150 monthly part B premium?
CalChris 3y ago
Medicare Advantage is not more of a free market than Traditional Medicare. Both restrict their markets but in different ways. MA restricts your access to doctors and sets fees. Someone on a Kaiser Permanente Medicare Advantage plan won't be able to go to the Mayo Clinic but the Mayo Clinic and Cedars Sinai do accept Traditional Medicare. In addition, you'll need preauthorization ("Delay, deny, die") from the insurance company for many procedures. On the other hand, TM sets the fees to what is called Medicare Assignment (and also allows something else called Excess Charges). But any doctor can accept Medicare Assignment. At UCSF, I need a referral for a colonoscopy for which Medicare pays Assignment but then I don't need a preauthorization from Medicare for that. My elevator argument for Traditional Medicare (A+B+G+D) and against Medicare Advantage (Part C) is: why would you want to spend the rest of your life arguing with an insurance company?
- jasode 3y ago
  >My elevator argument [...] against Medicare Advantage (Part C) is: why would you want to spend the rest of your life arguing with an insurance company? It's an affordability issue so it's not as simple as you laid it out. Some corporate-sponsored health benefit plans for retired ex-employees pay 100% for Medicare Advantage and not Traditional Medicare + Medigap. The UHC Medicare Advantage has some aspects of "Medigap" included in that plan and 100% of that total premium is reimbursed by the company. So choices are: - $0.00/month for Medicare Advantage - $2100/year out-of-pocket for Traditional Medicare + $$$ extra for Medigap That's the tradeoff math that some seniors contend with. Some choose to hypothetically "argue with an insurance company" because they don't have $2100 to spare.
  - CalChris 3y ago
    No, it's not an affordability issue and you're not getting something for nothing. First, you assign your Medicare benefit over to a corporation who then covers your health care costs at their discretion. Then you'll pay your Part B premium ($174.70/mo) out of your Social Security benefit. So you will have the magical illusion of a $0.00/mo premium and the insurance company then makes a substantial profit to boot. I spend about $300/mo for A+B+G+D. My OOP max is the $240 Part B deductible (except for drugs but I only take a statin). That will go up over time, Community Pricing. I have no preauthorizations, no copays, no coinsurance. And generally no paperwork. When I went to my UCSF PCP for a sprained MCL, I made an appointment a few days later. I showed up and said who I was. A few minutes later I saw the doc. After that I walked out. The wallet stayed in the pants and I didn't fill out a single form. A colonoscopy had a little paperwork, disclosures and actual ID. I watch the billing on MyChart, but it's a spectator rather than participatory sport. It's UCSF vs Medicare and it settles in a month or so. A+B+G+D is by far the best health insurance I've had in my life.
pdonis 3y ago
> Is it that last part that turns this into the "free market"? No. "Having private companies do it" is not the same as "free market". Nor is "for profit".
jml78 3y ago
Advantage plans deny coverage that Medicare covers. I just went thru the nightmare. My mom had a stroke. She was up and walking the day after and the next day. After day 1, they applied for PT and OT. Her plan delayed delayed delayed. She developed a bedsore and blood clots due to the hospital not having the resources. But it would have never happened had approval been guaranteed like Medicare. They would have moved her after day 1 to PT and OT. But with advantage plans you must get approval. Medicare never dies these things. She never walked again after day 2 of her stroke. She died a month and a half later. Her advantage plan tried to deny any additional resources after day 21 that weren’t send her to my home with me being the full time care giver. I email bombed the advantage plan board of directors asking wtf they would do in my situation. The hospital would not release her into my care because I had nowhere for her. And her advantage plan denied paying for a skilled nursing facility saying she wasn’t ill enough. After my emails, I managed to get them to approve skilled nursing. It was a nightmare. Fuck all Medicare advantage plans. They fuck people over and make family members deal with BS when they should just be worried about their loved ones.

by jack_h 3y ago

borski 3y ago

Yes, it’s the last part. Medicare has set prices it will pay [0], period, and Medicare is not prone to denying procedures that a physician thinks is necessary. This is a public socialized good. MA plans negotiate with providers, similar to a regular commercial insurance company, for different “deals.” As you may be aware from commercial insurance, that typically means higher rates, since everyone along the line has to get paid across the providers and the insurance companies. Much higher profit motive than a socialized good. On top of that, MA plans have an incentive to deny coverage wherever possible, because as a for-profit entity they want to make as much money as possible, not get old people healthier. Young people have trouble fighting insurers on denials. I know this firsthand. But it’s doable, because we tend to have more energy and less cognitive impairment; I’m generalizing here, but dementia is a thing that happens to a lot of people in old age, for example. For older people, fighting insurance companies is just about impossible. Often, this falls on their younger family members to help (ask me how I know, lol), but that implies their family or friends are willing to help. Not everyone has that. And it shouldn’t be that way. [0] There is a thing called Excess Charges that providers can charge, if they don’t accept the Medicare fee table, but still accept Medicare generally. They have to tell you before the service, or you are not responsible. It is also capped at 15% of the service, and is illegal in some states entirely, and capped lower in others. Some Medigap plans also cover excess charges, but they are on the more expensive end.

pdonis 3y ago
"Profit motive" is not the same as "free market". In a free market in health care, the only way to make profits would be to provide genuine services that are of value to the patients who are paying for them. In our actual system, lots of profits can be made by specializing in working the system that has been put in place by the government, to the detriment of patients. I totally agree that it shouldn't be this way. I just don't agree that the way to fix it is more socialized control by the government.
- Tagbert 3y ago
  A free market involves choices, information, and the ability to change choices based on that information. With health insurance the choices may be limited, you have very little information about what things cost and whether insurance will cover a given procedure. Most people are not educated well enough to be able to properly evaluate their options. You are only able to change your choice once a year. This is a free market in name only. But the impact of choosing incorrectly is very expensive.
- borski 3y ago
  The US government did not invent insurance. If a company wanted to compete with an existing insurance company but do it differently, they can already do that; direct primary care offerings exist right now. Healthcare, when coupled with a profit motive, offers misaligned incentives, period. Getting people healthier for cheaper doesn't make a healthcare company money. That is why I believe basic healthcare should be socialized. That doesn't mean we can't have private companies offering countless other medical services or additional insurance, but nobody should be getting denied a cochlear implant because they are deaf due to 'paperwork issues' for months or years until they die.
  - pdonis 3y ago
    > The US government did not invent insurance. I never claimed it did. My claim is that what we call "health insurance" in the US is not just insurance; it is a bundle of insurance (coverage for high cost unforeseen events) with other things that aren't insurance, but have to be bundled with it because the government says so. > direct primary care offerings exist right now. Yes, they do, but they are hamstrung by the fact that the US health care system disincentivizes patients from using them. If all primary care in the US was provided by such places, and patients paid the costs directly, that would be a free market, at least in primary care. But that's nothing like what we have. It's certainly nothing like what Medicare Advantage, which is the subject of this discussion, provides. > Healthcare, when coupled with a profit motive, offers misaligned incentives, period. Not in a free market. Health care in the US before WW II was provided by private companies (or individuals like doctors with their own practices), for profit, and worked better, given the technology of the time, than what we have now. What ended that system was laws passed during WW II that fixed wages, which meant that companies could not compete for labor in a free market by offering higher wages. So companies looked around for other benefits they could offer to compete, and health care was an obvious one. And then after the war the government decided to regulate the company-provided health care instead of ending it and restoring a free market. What offers misaligned incentives is the bastardized system we have in the US, which combines the worst features of for-profit with the worst features of socialism. The for-profit part is not visible to the actual patients--as I have already pointed out upthread, patients have no idea what the services they are getting actually cost, so they have no idea whether they are worth what they cost. The socialized part is what patients see--the services available to them are determined by their health "insurance", not them--but decisions are made by third parties who have no skin in the game and suffer no consequences when they make bad decisions that cause harm to patients. > nobody should be getting denied a cochlear implant because they are deaf due to 'paperwork issues' for months or years until they die. Of course not. And this would not happen in a free market. It happens because we don't have a free market in cochlear implants, we have a non-free market system with misaligned incentives, as I described above.

IG_Semmelweiss 3y ago

Its not free market but its technically more choice. Basically its taking a subsidy (Medicare funding") and offering it to 3rd parties willing to offer equal value, but shuffled around so the benefits are "chosen" by patients who know what's best for them. Here is the secret: in almost all cases, regular medicare is better for most patients. You may pay more upfront (coins, copay) but there are fewer surprises.

borski 3y ago
If they incentivize every insurance company the same way, and in the same amount, it is still a free market. The playing field is still level.
CalChris 3y ago
Traditional Medicare pays most but not all of covered health care costs. So to cover the gap in coverage there are private standardized Medigap plans. Plan G has no copays, coinsurance or deductibles except for the Part B deductible ($240/yr). Love Plan G. I would argue that Traditional Medicare has much more choice; most doctors+hospitals and all ERs accept Medicare Assignment. You can also go to the Mayo Clinic, Cleveland or Cedars Sinai with TM but rarely with MA.
- tpmoney 3y ago
  Doesn’t plan G have something like a 300-400 monthly premium on top of your $150 monthly part B premium?

CalChris 3y ago

Medicare Advantage is not more of a free market than Traditional Medicare. Both restrict their markets but in different ways. MA restricts your access to doctors and sets fees. Someone on a Kaiser Permanente Medicare Advantage plan won't be able to go to the Mayo Clinic but the Mayo Clinic and Cedars Sinai do accept Traditional Medicare. In addition, you'll need preauthorization ("Delay, deny, die") from the insurance company for many procedures. On the other hand, TM sets the fees to what is called Medicare Assignment (and also allows something else called Excess Charges). But any doctor can accept Medicare Assignment. At UCSF, I need a referral for a colonoscopy for which Medicare pays Assignment but then I don't need a preauthorization from Medicare for that. My elevator argument for Traditional Medicare (A+B+G+D) and against Medicare Advantage (Part C) is: why would you want to spend the rest of your life arguing with an insurance company?

jasode 3y ago
>My elevator argument [...] against Medicare Advantage (Part C) is: why would you want to spend the rest of your life arguing with an insurance company? It's an affordability issue so it's not as simple as you laid it out. Some corporate-sponsored health benefit plans for retired ex-employees pay 100% for Medicare Advantage and not Traditional Medicare + Medigap. The UHC Medicare Advantage has some aspects of "Medigap" included in that plan and 100% of that total premium is reimbursed by the company. So choices are: - $0.00/month for Medicare Advantage - $2100/year out-of-pocket for Traditional Medicare + $$$ extra for Medigap That's the tradeoff math that some seniors contend with. Some choose to hypothetically "argue with an insurance company" because they don't have $2100 to spare.
- CalChris 3y ago
  No, it's not an affordability issue and you're not getting something for nothing. First, you assign your Medicare benefit over to a corporation who then covers your health care costs at their discretion. Then you'll pay your Part B premium ($174.70/mo) out of your Social Security benefit. So you will have the magical illusion of a $0.00/mo premium and the insurance company then makes a substantial profit to boot. I spend about $300/mo for A+B+G+D. My OOP max is the $240 Part B deductible (except for drugs but I only take a statin). That will go up over time, Community Pricing. I have no preauthorizations, no copays, no coinsurance. And generally no paperwork. When I went to my UCSF PCP for a sprained MCL, I made an appointment a few days later. I showed up and said who I was. A few minutes later I saw the doc. After that I walked out. The wallet stayed in the pants and I didn't fill out a single form. A colonoscopy had a little paperwork, disclosures and actual ID. I watch the billing on MyChart, but it's a spectator rather than participatory sport. It's UCSF vs Medicare and it settles in a month or so. A+B+G+D is by far the best health insurance I've had in my life.

pdonis 3y ago

> Is it that last part that turns this into the "free market"? No. "Having private companies do it" is not the same as "free market". Nor is "for profit".

jml78 3y ago

Advantage plans deny coverage that Medicare covers. I just went thru the nightmare. My mom had a stroke. She was up and walking the day after and the next day. After day 1, they applied for PT and OT. Her plan delayed delayed delayed. She developed a bedsore and blood clots due to the hospital not having the resources. But it would have never happened had approval been guaranteed like Medicare. They would have moved her after day 1 to PT and OT. But with advantage plans you must get approval. Medicare never dies these things. She never walked again after day 2 of her stroke. She died a month and a half later. Her advantage plan tried to deny any additional resources after day 21 that weren’t send her to my home with me being the full time care giver. I email bombed the advantage plan board of directors asking wtf they would do in my situation. The hospital would not release her into my care because I had nowhere for her. And her advantage plan denied paying for a skilled nursing facility saying she wasn’t ill enough. After my emails, I managed to get them to approve skilled nursing. It was a nightmare. Fuck all Medicare advantage plans. They fuck people over and make family members deal with BS when they should just be worried about their loved ones.