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Medicare Advantage and Those with Chronic Illnesses

By July 2, 2023Commentary

One claim about Medicare Advantage plans was that they sought only healthy enrollees to keep costs down and raise profits.  More expensive beneficiaries typically have multiple chronic illnesses and other needs.  This has been false forever, the plans actually wanted sicker beneficiaries because they got paid more for them and had more opportunity to better manage care and lower costs.  Another piece of research validates this perspective, finding that persons with chronic diseases were no more likely to disenroll from MA plans than those beneficiaries without chronic illness.  This suggests that they felt their needs were well-met by the plans.  (JAMA Article)

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  • Anthony D says:

    The relatively low rate of switching from Medicare Advantage to traditional Medicare does not necessarily support the conclusion, “This suggests that [the enrollees] felt their needs were well-met by the plans.” Perhaps “adequately” would be more accurate than “well-met:” 1) “Needs” are both medical and economic. From a medical perspective, some health systems provide better or more advanced care in certain disease states than do other nearby systems; in some regions, MA plans may not allow access to both systems. From an economic perspective, many seniors and dual-eligibles may not have the financial resources to pay for traditional Medicare, even if the greater flexibility and wider access would be beneficial from a quality-of-care standpoint. 2) Some “needs” may be both medical and economic. For example, in my region copays for new, highly beneficial brand-name drugs in cardiology (i.e., there are no generic alternatives) vary widely among MA plans, and it is the uncommon patient who has ever used a Medicare advisor or performed a search on to see if their Entresto, Jardiance, Eliquis, etc. would be less expensive on a different MA (or Part D) plan.
    In sum, from my perspective in the trenches, I see both wealthy patients who choose MA plans who are then surprised when their new diagnosis does not allow them to switch to the system or physician they would prefer, and I see some (though not as many) who have limited resources who are in FFS who would be much better off in an advantage plan. This is likely due to the lack of preparation so many fail to perform in the year (or more) before they are thrust onto Medicare.

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