topic Re: Getting medicare costs under control in Wellness

Getting medicare costs under control

151949 — Mon, 09 May 2016 17:42:34 GMT

I heard that one candidiate who shall go unnamed has a plan to help get medicare costs under control and it is to make ALL supplements be HMO or PPO type plans. I am all for this as it has already proven to be very cost effective in the private sector for the PCP to have some control. It is unfortunate that when people are allowed to see any doctor they want as much as they want - how medicare is now - there is a segment of people who are very abusive of this. We read here on the board all the time that someone went to 6 different doctors for some problem because they weren't being told what they wanted to hear. Well, that behavior costs Medicare a ton of money. When someone wants to see 6 doctors - fine - but that person should have to pay for it then, not the taxpayer. Why should it be on the taxpayer to pay for people to doctor shop all over town? I know the hypocondriacs won't like it but that is their problem - I find this to be a very viable solution to a lot of medicare's issues.

Re: Getting medicare costs under control

Tinkrbl44 — Mon, 09 May 2016 17:46:37 GMT

Interesting comments @151949 ....

I have to mull this one over and will comment later.

Re: Getting medicare costs under control

gidgetgh — Mon, 09 May 2016 18:03:51 GMT

Aren't all Medicare supplements now either HMO's or PPO's?

My husband's supplement (plan F through Blue Cross) is a PPO. His PCP doesn't have to coordinate any of his care.

Re: Getting medicare costs under control

151949 — Mon, 09 May 2016 18:08:51 GMT

@gidgetgh Very few medicare supplements are HMO/PPO - very very few. Are you sure your husband doesn't have an advantage plan? They are mostly HMO/PPO plans. Supplements and advantage plans are not the same thing.

When you have a PPO plan and go out of network it is usually a very high copay - that is how they keep you in the network.

Re: Getting medicare costs under control

gidgetgh — Mon, 09 May 2016 18:22:56 GMT

@151949 wrote:
@gidgetgh Very few medicare supplements are HMO/PPO - very very few. Are you sure your husband doesn't have an advantage plan? They are mostly HMO/PPO plans. Supplements and advantage plans are not the same thing.
When you have a PPO plan and go out of network it is usually a very high copay - that is how they keep you in the network.

@151949- I am absolutely positive he doesn't have an advantage plan. Traditional Medicare and Blue Cross Plan F supplement. He has no co-pay for any doctor or hospital, lab, etc. Plan F picks up everything Medicare doesn't cover and covers all the co-Pays.

Re: Getting medicare costs under control

Moonchilde — Mon, 09 May 2016 18:36:27 GMT

IMO rather than mandatory filtering through a PCP, there needs to be a cap on the # of specialists one can go to through Medicare, i.e. a second, and perhaps a share-the-cost third opinion should remain an option, and after that it's out-of-pocket.

Many (many!) times people are in serious situations where they need a specialist appt without undue delay. Many PCP offices make even their acutely ill patients wait 3 weeks to be seen (just happened in my household, necessitating 2 separate visits to an urgent care center instead). That sure wasn't cost-saving :-(

We know the supply of doctors is shrinking. In certain areas they are spread very thinly indeed. I foresee more and more issues with the time it will take to get in to see a PCP in order to be referred, and in some cases this could be dangerous or needlessly uncomfortable for the patient.

I agree with the need for some sort of cap in letting the patient make the decisions and spending the govt's money, but I don't know that I think the overspending is endemic and widespread.

Re: Getting medicare costs under control

151949 — Mon, 09 May 2016 18:38:51 GMT

@gidgetgh wrote:
@151949 wrote:
@gidgetgh Very few medicare supplements are HMO/PPO - very very few. Are you sure your husband doesn't have an advantage plan? They are mostly HMO/PPO plans. Supplements and advantage plans are not the same thing.
When you have a PPO plan and go out of network it is usually a very high copay - that is how they keep you in the network.
@151949- I am absolutely positive he doesn't have an advantage plan. Traditional Medicare and Blue Cross Plan F supplement. He has no co-pay for any doctor or hospital, lab, etc. Plan F picks up everything Medicare doesn't cover and covers all the co-Pays.

OK I believe you. PPO stands for Perferred provider organization - in other words , a network. So if they pay everything for him no matter what doctor he goes to what would be an advantage to them to have a network? What is his incentive to stay in the network? It doesn't make sense.

Re: Getting medicare costs under control

151949 — Mon, 09 May 2016 18:44:25 GMT

@Moonchilde wrote:
IMO rather than mandatory filtering through a PCP, there needs to be a cap on the # of specialists one can go to through Medicare, i.e. a second, and perhaps a share-the-cost third opinion should remain an option, and after that it's out-of-pocket.

Many (many!) times people are in serious situations where they need a specialist appt without undue delay. Many PCP offices make even their acutely ill patients wait 3 weeks to be seen (just happened in my household, necessitating 2 separate visits to an urgent care center instead). That sure wasn't cost-saving :-(

We know the supply of doctors is shrinking. In certain areas they are spread very thinly indeed. I foresee more and more issues with the time it will take to get in to see a PCP in order to be referred, and in some cases this could be dangerous or needlessly uncomfortable for the patient.

I agree with the need for some sort of cap in letting the patient make the decisions and spending the govt's money, but I don't know that I think the overspending is endemic and widespread.

Private insurance found they saved a ton of money when they went with the HMO /PPO options, and that is why they have all stayed with them.

As for limiting how many specialists a person can see - what if a person has multiple diseases and needs several different specialists? Many patients have more than one or two medical issues. What if you were seeing all the specialists you were allowed and then suddenly needed a surgeon? I don't see that as a solution.

Re: Getting medicare costs under control

gidgetgh — Mon, 09 May 2016 18:52:27 GMT

@151949 wrote:
@gidgetgh wrote:
@151949 wrote:
@gidgetgh Very few medicare supplements are HMO/PPO - very very few. Are you sure your husband doesn't have an advantage plan? They are mostly HMO/PPO plans. Supplements and advantage plans are not the same thing.
When you have a PPO plan and go out of network it is usually a very high copay - that is how they keep you in the network.
@151949- I am absolutely positive he doesn't have an advantage plan. Traditional Medicare and Blue Cross Plan F supplement. He has no co-pay for any doctor or hospital, lab, etc. Plan F picks up everything Medicare doesn't cover and covers all the co-Pays.
OK I believe you. PPO stands for Perferred provider organization - in other words , a network. So if they pay everything for him no matter what doctor he goes to what would be an advantage to them to have a network? What is his incentive to stay in the network? It doesn't make sense.

@151949- yeah, I agree with you. Maybe we just haven't run into anyone out of network yet. His PCP and Neurologist both take both and last year when he was hospitalized and had surgery, Medicare and Blue Cross covered everything, including the two ambulance trips. In or out of network never came up and it didn't occur to me to ask as each physician, etc. came in his room.

Re: Getting medicare costs under control

Moonchilde — Mon, 09 May 2016 19:06:27 GMT

@151949 wrote:
@Moonchilde wrote:
IMO rather than mandatory filtering through a PCP, there needs to be a cap on the # of specialists one can go to through Medicare, i.e. a second, and perhaps a share-the-cost third opinion should remain an option, and after that it's out-of-pocket.

Many (many!) times people are in serious situations where they need a specialist appt without undue delay. Many PCP offices make even their acutely ill patients wait 3 weeks to be seen (just happened in my household, necessitating 2 separate visits to an urgent care center instead). That sure wasn't cost-saving :-(

We know the supply of doctors is shrinking. In certain areas they are spread very thinly indeed. I foresee more and more issues with the time it will take to get in to see a PCP in order to be referred, and in some cases this could be dangerous or needlessly uncomfortable for the patient.

I agree with the need for some sort of cap in letting the patient make the decisions and spending the govt's money, but I don't know that I think the overspending is endemic and widespread.
Private insurance found they saved a ton of money when they went with the HMO /PPO options, and that is why they have all stayed with them.
As for limiting how many specialists a person can see - what if a person has multiple diseases and needs several different specialists? Many patients have more than one or two medical issues. What if you were seeing all the specialists you were allowed and then suddenly needed a surgeon? I don't see that as a solution.

Multiple diseases requiring specialists = for each specialist needed, not cumulative.

It's always good to save $$ and cut down on costs, but not at the expense of quality of care/neglect, i.e. waiting an inordinate amount of time to see a PCP and then further delay in getting an appt with a specialist. What if we're talking eyes here, for example. With the best judgment and best intentions, office staff might still cost a person their eyesight, in a worst case scenario. We'd all like to believe that wouldn't happen, but not every doctor, or practice, is what it should be. And who wants to be the test case?

I'm not disagreeing with you entirely - I rarely see things in black and white, i.e. all wrong or all right, good/bad, etc. There should be room for discussion and compromise in most things, IMO, especially on a discussion forum.

Re: Getting medicare costs under control

151949 — Mon, 09 May 2016 20:06:02 GMT

@MoonchildeThe thing is - almost all Americans who are not on medicare are on workplace based insurance and a huge % of those are HMO/PPO plans. I personally was in an HMO ever since the concept was first thought of. So why should medicare patients feel they have a right to a better and much more expensive care model than almost everyone else ? HMOs are not a bad thing, they do take a little adjusting of how you see things, but once you get used to the concept it is fine. Just because someone is in an HMO does not in any way mean they get inferior care.

For instance - I needed knee surgery - my doctor sent me to an ortho doctor who was in network. He determined that I only needed a mini procedure called makoplasty instead of an entire TKR which I was glad to hear. The hospital that had the robot that does the makoplasty was at an out of network hospital - I called the insurance company and they called me back within an hour to tell me the procedure had been approved and would be paid 100%. A few days later I got a letter confirming my phone conversation, and about 2 weeks later had my surgery. 3 months later I had the same on the other knee. Absolutely no difference than someone who has a plan F type medicare plan.For some reason I can't understand , people are afraid of HMOs and I think it is just silly. Plus, if you have an HMO and there is a doctor in the network who is getting bad patient results the HMO would dump him in a NY min. because he would be costing them money and giving them a bad reputation.

Re: Getting medicare costs under control

Tinkrbl44 — Mon, 09 May 2016 22:32:53 GMT

@151949 wrote:
@MoonchildeThe thing is - almost all Americans who are not on medicare are on workplace based insurance and a huge % of those are HMO/PPO plans. I personally was in an HMO ever since the concept was first thought of. So why should medicare patients feel they have a right to a better and much more expensive care model than almost everyone else ? HMOs are not a bad thing, they do take a little adjusting of how you see things, but once you get used to the concept it is fine. Just because someone is in an HMO does not in any way mean they get inferior care.
For instance - I needed knee surgery - my doctor sent me to an ortho doctor who was in network. He determined that I only needed a mini procedure called makoplasty instead of an entire TKR which I was glad to hear. The hospital that had the robot that does the makoplasty was at an out of network hospital - I called the insurance company and they called me back within an hour to tell me the procedure had been approved and would be paid 100%. A few days later I got a letter confirming my phone conversation, and about 2 weeks later had my surgery. 3 months later I had the same on the other knee. Absolutely no difference than someone who has a plan F type medicare plan.For some reason I can't understand , people are afraid of HMOs and I think it is just silly. Plus, if you have an HMO and there is a doctor in the network who is getting bad patient results the HMO would dump him in a NY min. because he would be costing them money and giving them a bad reputation.

@151949

It's my experience that people either love or hate HMOs.

You have to keep in mind that these are managed care plans, and the job of the PCP is to cut costs and discourage additional testing. If you're healthy and don't need to see an MD very often, they can be very cost efficient. BUT .... for example, if a person is diagnosed with cancer, for instance, and does research online for treatments, it's possible the HMO Oncologist will deny that treatment option " because you don't need that". Should they believe them, or should they pay out of pocket for treatments the HMO denies?

I also don't like the idea of needing permission to see a doctor, and not being able to choose my own. I've had PPOs all my adult life, and am happy to pay extra for the ability to choose my own doctors. JMO

Re: Getting medicare costs under control

hckynut — Mon, 09 May 2016 23:43:52 GMT

@Tinkrbl44 wrote:
For some reason I can't understand , people are afraid of HMOs and I think it is just silly.

I also don't like the idea of needing permission to see a doctor, and not being able to choose my own. I've had PPOs all my adult life, and am happy to pay extra for the ability to choose my own doctors. JMO

i will always choose what doctors I see just as I have in the past pre being on Medicare. I agree with what you have said and, when/if ever necessary, will pay.

hnj

Re: Getting medicare costs under control

Carmie — Mon, 09 May 2016 23:52:06 GMT

Medicare costs are already cut to the bone. There are many doctors who refuse to see too many Medicare patients or none at all. The government has cut Medicare payments to a small fraction of what the doctor bills or needs to stay afloat.

HIPAA has required medical professionals and facilities to to onboard with all of the new requirements in record keeping and billing. This is a BIG cost. In order to practice medicine, doctors now practice in groups. Not many can keep open a one man/woman office anymore. They have to pool their office help..all contributing their share.

The current price for Medicare Part B is $121.80 a month. In addition, people who purchase a supplement pay more than that a month for medical coverage.

Seniors who have an advantage plan pay the Medicare Part B premium and some pay a small additional payment and some plans cost $0 in addition to Medicare. These folks can save a lot of money if they are healthy. If they must see many providers for illness their out of pocket expenses can get expensive. Those copayments can add up.

Those Advantage Medicare plans are dropping off. They are not cost effective for insurance companies and they are losing millions each year. Soon, you may not find any insurance companies offering them.

My take on Traditional Medicare with a Supplemental plan is that they are expensive. You get what you pay for. The people who choose to pay for them deserve to go to any medical provider they want to and receive all medically necessary services they require because they are paying BIG money to be able to do so.

I know you have an Advantage plan that was very cost effective for you and your DH for many years. Now that you need more medical services and need the services more often, your copayments and out-of-pocket expenses are going up.

You have also igured out that it is cost prohibited for you to change your coverage to Traditional Medicare with a supplement now.

Choosing health insurance at age 65 is difficult and whatever you choose is probably what you will have for the rest of your life. It's a gamble.

Why comment about people who you think abuse Medicare? Medicare is audited big time.. They look for and find abuse. More abuse is being done by doctors than by any patients. Doctors are billing Medicare for services they are not providing. This is costing Medicare BILLIONS!

For years I have been telling you that Advantage plans can be expensive in the long run, but you doubted me and got very defensive, to put it mildly.

Now it's too late for you, you made your bed and you have to lay in it. So, stop complaining about other people,

PS: the poster who you think is abusing the system only has Medicare. Medicare pays 80% and since she has NO supplement, she must,pony up 20% of each out patient service she has. In addition she pays her Inpatient deductible which is $1288.

It's time to give it a rest and let it go.

Re: Getting medicare costs under control

GingerPeach — Tue, 10 May 2016 00:25:06 GMT

@gidgetgh wrote:
Aren't all Medicare supplements now either HMO's or PPO's?

My husband's supplement (plan F through Blue Cross) is a PPO. His PCP doesn't have to coordinate any of his care.

Unless your state is unusual, @gidgetgh, Plan F is a supplement plan.

The Medicare.gov site is a good one to answer all questions.

Supplement plans (A-N) are just that, supplement plans. They are also called Medigap policies: https://www.medicare.gov/supplement-other-insurance/medigap/whats-medigap.html

Insurance companies offer supplement plans, but that does not make them the same as network plans offered by insurance companies.

Advantage plans are either an HMO or a PPO. Those have networks, the supplement plans do not have networks.

https://www.medicare.gov/supplement-other-insurance/compare-medigap/compare-medigap.html

Re: Getting medicare costs under control

Tinkrbl44 — Tue, 10 May 2016 00:28:27 GMT

@Carmie

Are you talking to anyone specifically, or to everyone, generally?

What I have learned from all that I know who are on Medicare is that the traditional + supplement are more expensive monthly but there are fewer out of pocket surprises down the road. For those on a budget, it's a more predictable plan. Those on the Advantage may be paying less per month, but when that first big medical surprise comes, sticker shock will definitely follow.

IMO, None of us has a crystal ball ... and you do get what you pay for.

Re: Getting medicare costs under control

151949 — Tue, 10 May 2016 00:45:08 GMT

@Tinkrbl44 wrote:
@Carmie

Are you talking to anyone specifically, or to everyone, generally?

What I have learned from all that I know who are on Medicare is that the traditional + supplement are more expensive monthly but there are fewer out of pocket surprises down the road. For those on a budget, it's a more predictable plan. Those on the Advantage may be paying less per month, but when that first big medical surprise comes, sticker shock will definitely follow.

IMO, None of us has a crystal ball ... and you do get what you pay for.

ALL medicare advantage plans have a max out of pocket limit - my insurance that is $6700. I can afford to pay $6700 if that was necessary.I would not be happy about it but I am more willing to have a rare possible chance I may have to pay $6700 if one of us got sick than pay over $800 a month , every month for both of us to have a plan F supplement and a drug plan, which are compreable to the coverage I have. At that rate every 8 months we have saved our $6700.

Re: Getting medicare costs under control

glorybe — Tue, 10 May 2016 01:25:58 GMT

@151949 wrote:
I heard that one candidiate who shall go unnamed has a plan to help get medicare costs under control and it is to make ALL supplements be HMO or PPO type plans. I am all for this as it has already proven to be very cost effective in the private sector for the PCP to have some control. It is unfortunate that when people are allowed to see any doctor they want as much as they want - how medicare is now - there is a segment of people who are very abusive of this. We read here on the board all the time that someone went to 6 different doctors for some problem because they weren't being told what they wanted to hear. Well, that behavior costs Medicare a ton of money. When someone wants to see 6 doctors - fine - but that person should have to pay for it then, not the taxpayer. Why should it be on the taxpayer to pay for people to doctor shop all over town? I know the hypocondriacs won't like it but that is their problem - I find this to be a very viable solution to a lot of medicare's issues.

@151949 I think you are forgetting some things here like the fact that not all of us have a variety of physicians where we live that would be open to being part of a PPO or HMO. I know from prior experience, before I was on Medicare and had a PPO, that they can change from one day to the next to quit taking it. In fact, I believe I can recall you complaining about this when you were faced with a similar situation in the past.

As for going to more than one physician for the same problem, ever heard of second and, in some cases, third opinions so the best possible outcome can be attained!

Some of us have multiple medical problems, some from birth, so we have to see a variety of Specialists and have no choice but to use Medicare for which we pay and also pay for a Supplement!

Re: Getting medicare costs under control

Moonchilde — Tue, 10 May 2016 01:02:38 GMT

@151949, I was in an HMO plan through my employer for about the last 16 years while I was working, so I'm familiar with their fees, ins and outs - and the downside - namely that even though I lived in an area with world-class physicians coming out your virtual ears, I and my co-workers were saddled with a *very small* pool of PCPs through BC and later BS.

When referrals were necessary, that pool was even smaller - usually 1-2 in each specialty. Often we felt we were getting substandard care from our referrals, or that things were not done that should have been done to keep costs down - and we were coming from the POV of most of us having spent decades in healthcare. I had one co-worker who only needed to pass upcoming boards to get her MD; plus, we worked for doctors - so it wasn't ignorance talking.

I think that while the American public could exist fairly content under a PPO system, a strict HMO system would cause panic for many, and again, it would severely restrict the standard of care.

I look forward to making my own informed choices when it's appropriate for me to do that, and to having the "freedom" of choosing my own PCP - which IMO should be a basic right. I will have no problem going to a specialist my PCP suggests - unless and until I feel I'm getting substandard care, and then I thank multiple deities that if I truly feel I need to make a change, I will be able to.

BTW, I know all about "doctor shoppers" - I personally dealt with them weekly in my job - and I could and would never be one. But that's not the same as simply having basic choices.

And I totally agree that there should be measures to prevent wholesale abuse, when it's there - but like others have said, it's easier for MDs to abuse the system than for patients. Plus, those who do abuse will get it in the end ;-( by having huge increases in their premiums once their medigap company sees what they're doing.

Re: Getting medicare costs under control

glorybe — Tue, 10 May 2016 01:20:52 GMT

@Moonchilde wrote:
@151949, I was in an HMO plan through my employer for about the last 16 years while I was working, so I'm familiar with their fees, ins and outs - and the downside - namely that even though I lived in an area with world-class physicians coming out your virtual ears, I and my co-workers were saddled with a *very small* pool of PCPs through BC and later BS.

When referrals were necessary, that pool was even smaller - usually 1-2 in each specialty. Often we felt we were getting substandard care from our referrals, or that things were not done that should have been done to keep costs down - and we were coming from the POV of most of us having spent decades in healthcare. I had one co-worker who only needed to pass upcoming boards to get her MD; plus, we worked for doctors - so it wasn't ignorance talking.

I think that while the American public could exist fairly content under a PPO system, a strict HMO system would cause panic for many, and again, it would severely restrict the standard of care.

I look forward to making my own informed choices when it's appropriate for me to do that, and to having the "freedom" of choosing my own PCP - which IMO should be a basic right. I will have no problem going to a specialist my PCP suggests - unless and until I feel I'm getting substandard care, and then I thank multiple deities that if I truly feel I need to make a change, I will be able to.

BTW, I know all about "doctor shoppers" - I personally dealt with them weekly in my job - and I could and would never be one. But that's not the same as simply having basic choices.

And I totally agree that there should be measures to prevent wholesale abuse, when it's there - but like others have said, it's easier for MDs to abuse the system than for patients. Plus, those who do abuse will get it in the end ;-( by having huge increases in their premiums once their medigap company sees what they're doing.

@Moonchilde TRUTH! We pay for what we get! I have Medicare which I pay for Part B and also pay for Plan F Supplement. I have multiple medical issues of which I have no control over, born with mild cerebral palsy which is causing multiple spine problems, etc. I choose to pay for my care as I see fit. I do not want PPO or HMO as limits on who I can see, when I can see them, if I can get a referral, etc. Been there, done that in the past when on Blue Cross/Blue Shield insurance

@151949 Who do you think supplements Medicare Advantage Plans? The Government does, so why should that be allowed when those type of plans are not even available in some areas and so those same people must contribute to keeping the Medicare Advantage Plans going for those people in the Advantage Plans to save money while others pay our own way at a higher cost?