Medicare Advantage grows,
but provider choice is limited
Send a link to a friend
[July 07, 2016]
By Mark Miller
CHICAGO (Reuters) - Medicare enrollees
are moving in greater numbers than ever to the program’s managed
care option as a way to save money. But the tradeoff is much less
ability to use their preferred doctors and hospitals.
Seniors can choose between traditional fee-for-service Medicare -
which is accepted by most healthcare providers - or a Medicare
Advantage plan. The latter encompasses health maintenance
organizations (HMOs) or preferred provider organizations (PPOs),
which control costs by creating healthcare provider networks that
enrollees must use.
In theory, prospective Advantage enrollees can review lists of
in-network providers before opting into a plan. But a new study by
the Kaiser Family Foundation (KFF) finds that provider data often is
very difficult to review, can be out of date and frequently contain
KFF’s review also found shortcomings in the quality of providers in
some Medicare Advantage provider networks. One out of every five
plans did not include a regional academic medical center -
institutions which usually offer the highest quality care and top
specialists. And only 40 percent of Advantage provider networks
included top-quality cancer centers, as indicated by membership in
the National Cancer Institute’s network.
NCI-designated cancer centers offer cutting-edge treatments and tend
to have greater access to clinical trials. They are especially
important for patients with rare and advanced cancers, or other
complicating conditions, said Gretchen Jacobson, KFF’s associate
director of the program on Medicare policy and co-author of the
The upshot: Medicare Advantage may be just fine if you are healthy,
but problems may crop up if your healthcare needs become more
complex and you have very specific healthcare provider preferences.
This year, 31 percent of Medicare enrollees are in Advantage plans,
up from 11 percent in 2010. That number is expected to hit 41
percent by 2026, according to a forecast by the Congressional Budget
When you sign up for Advantage, your Part B premium goes to the
insurance company providing the plan. The largest providers are
UnitedHealthcare, Humana Inc and Blue Cross Blue Shield.
One often hears critics claim that healthcare providers are bailing
out of traditional Medicare in large numbers - but that is not
actually the case. Last year, 14 percent of Medicare enrollees who
were seeking a new primary care doctor reported major problems in
finding a physician who would treat them, according to survey data
from the Medicare Payment Advisory Commission, an independent
congressional agency. Among those seeking a new specialist, 6
percent reported major problems. In both cases, that represents 1
percent of the total Medicare population.
Advantage plans often offer extra benefits, such as health club
memberships, vision care and some limited dental care. Cost-sharing
is often lower, and many plans provide prescription drug coverage
with no extra premium. “It can be very attractive to many seniors
who are living on a fixed budget,” Jacobson said.
[to top of second column]
The trade-off is limited provider networks - and the challenges prospective
enrollees face in determining who they are allowed to see for healthcare, and
who is off-limits. KFF reviewed 409 Advantage plans, including 307 HMOs and 102
PPOs. Researchers found provider directories often were riddled with errors,
omissions and outdated information.
“There’s no reason in this era of technology why this needs to be as difficult
as it is,” Jacobson said. “People should be able to simply tell the system who
their doctors are, the illnesses they have, and get a recommendation for a plan
that will work for them.”
KFF also found that Advantage provider network quality differs significantly.
For example, Los Angeles has three NCI-designated cancer centers. Most of the
Advantage plans there do not include any of them, but one plan includes all
A report last year by the U.S. Government Accountability Office found that the
Centers for Medicare & Medicaid Services (CMS), which runs Medicare, needs to
improve its oversight of Advantage plans to assure that provider networks are
robust. The report also criticized CMS for doing too little to assess the
accuracy of Advantage plan provider lists.
Even when Advantage enrollees are able to confirm participation by their
healthcare providers, there is no guarantee that will continue. Advantage plans
are free to add or drop health providers during the course of an enrollment
That became an especially hot issue in 2014 when UnitedHealthcare dropped
providers who covered thousands of the insurer's patients, including the
prominent Yale-New Haven Hospital system.
Democrats in Congress have proposed legislation that would prohibit Advantage
plans from dropping providers without cause during the middle of an enrollment
Under current rules, plans must provide 30 days’ notice to enrollees when
providers are dropped. Enrollees who lose access to a provider can make a
midyear plan change only under very limited circumstances. “You can do it only
if you are receiving ongoing care from a provider that is terminated,” Jacobson
said. “Otherwise you need to wait until the next open enrollment period.”
The annual enrollment period for Advantage and Part D prescription drug plans
are held from Oct. 15 to Dec. 7 each year. At that point, a beneficiary could
switch to a different Advantage plan, or shift back to traditional Medicare. But
a serious diagnosis in January would leave you hamstrung until the following
Said Jacobson: "It can be a roll of the dice."
(Editing by Matthew Lewis)
[© 2016 Thomson Reuters. All rights
Copyright 2016 Reuters. All rights reserved. This material may not be published,
broadcast, rewritten or redistributed.