By GEORGE HALVORSON
Special Needs Plans Change Lives for The Lowest Income and Highest Need Patients
The people who benefit the most from Medicare Advantage are clearly the very low-income and high health-need people who are eligible for both Medicare and Medicaid as programs and who enroll as members in the Medicare Advantage Special Needs Plan programs.
There clearly aren’t any other programs existing in our country that do more good for large numbers of needing people than the Medicare Advantage Special Needs Plans do for those members.
Those people with that dual eligibility are in major need for care.
We have millions of retirees who are eligible for both programs who have gone through years of inequities, inadequacies, and deficiencies relative to our care systems for a number of reasons, and who are now in need of care and support at multiple levels in their lives.
The plans do extremely good things for those high-need patients.
Medicare Advantage Special Needs Plan programs now help and provide services to millions of people who’ve actually never had good or adequate care in their entire lives.
The Special Needs Plan programs for Medicare Advantage reach into people’s homes and provide layers of service and support that are life changing, badly needed, and the Special Needs Plans are much appreciated, with very high satisfaction levels from the patients they serve for that better care and far better life support levels.
We tend, as a country, to abandon and under serve people in too many settings and communities who are old and who have no money and who are in significant need of care. The Medicare Advantage programs do wonderful and badly needed things for many of those patients that we need to understand, appreciate, and then protect as we look at Medicare Advantage plans and the overall Medicare Advantage programs and approaches.
The people at MedPac who are trying so hard to reduce the benefit levels for Medicare Advantage members and who do shamelessly inaccurate, distorted, and clearly intentionally fake news pieces on the cost of Medicare Advantage plans are trying to undermine and weaken the Special Needs Plan program in order to somehow create a level playing field with higher income patients for Medicare for the patients who get the most benefits from those programs.
That’s a very bad practice, and protecting those high-income people is a very wrong functional priority for MedPac to have. But they have it year after year in uncaring, insensitive, and cold ways relative to those patients and they seem impervious to data and information from all of the plans about those patients and that care, and their need for those benefits and services in their lives.
We need MedPac to clean up their act relative to their lowest income people, and we need them to start telling the truth about the actual relative cost of Medicare Advantage.
And we very much need them to understand how much the lowest income members need those benefits.
We need them to stop saying that the plans are overpaid when they know better from having more than 6 million people enrolled as Special Needs Plan members and benefit levels, and when they know that two out of three of the lowest income Members are in plans, and it should be painfully obvious to even the most cold-hearted observer, that those people clearly need the care and benefits that they get there from the plans.
The Medicare Advantage attacks from MedPac in their current report now say that the total cost of Medicare Advantage is 22% higher than those members would have cost as normal Medicare members.
They actually say in their most recent report that if all of the Medicare Advantage enrollees were now actually enrolled in fee-for-service Medicare, those enrollees who are currently in the plans would cost 22% less money for the overall Medicare program.
That’s obviously impossible and it’s a complete fabrication that they do not support in their document with even a wisp of data.
They use that false information, and they use a very skillful and intentional fake news context to attack the plans with that information.
They say that the Medicare Advantage coding practices by the plans inflate the payment level, and they defend their 22% overpayment number by saying that there is a long-standing selection process that used to happen for the plans whereby the healthier people joined Medicare Advantage, and the MedPac current report actually says that positive selection outcome in the risk distribution levels is the reason why the plans have financial surpluses in each county.
That accusation is impossible, clearly bad, blatantly incorrect, and obviously wrong, and they should obviously know how wrong it is just by looking at who has enrolled in the plans and thinking about what they see.
The people enrolled in the Medicare Advantage Special Needs Plans are eligible for both Medicaid and Medicare coverage and those millions of people have the highest health care needs in the country.
Having MedPac continuing to say directly and explicitly that the costs of millions of those high-need and extremely visible people are somehow more than completely offset by some historic level of risk skimming that was done in the past by the plans in some settings is absurd, impossible, nonsensical, ethically flawed and damaged, shamelessly intentionally misleading, maliciously untrue in a clearly morally challenged way, and absolutely wrong at multiple levels as a reality.
CMS and the Medicare Trustees Love the Special Needs Plans
CMS and the Medicare trustees love, appreciate, and salute the Special Needs Plans because they do so much good for people who very much need that care — and the trustees and the CMS teams very much want that better care to happen for the members.
The MedPac people actually do continue to say with a world-class fake-news straight face that the plans are overpaid by 22% because of plans risk skimming the membership in some logistically powerful way and having those risk skims increase the cash flow to the plans to the point that the plans are overpaid.
The truth is that care is much better for members of the plans and that the differences in care patterns are based on process improvement and not on any skimming risk by the plans.
The truth is that the care is far better for all of the members, and the numbers are beyond debate or dispute when you look at what they actually are.
We know that the plans have 40% fewer hospital admissions for congestive heart failure, and almost 80% lower amputation rates for the lowest income diabetic members, and we know that the plans use those savings from better care to also to provide much better benefits for all of the members.
Those additional benefits created by the plan surpluses are very important to millions of people and we need everyone to understand how important those benefits are.
We are facing very difficult times for many retirees in this country today. Over half of the retirees don’t have retirement benefits — and for the African American and Hispanic retirees, over half of them don’t have any cash reserves for their retirement years.
That is extremely important information about millions of people that we need everyone looking at the Medicare program to understand.
When you don’t have any money at all and have retired, the Medicare Advantage dental benefit and vision benefit and hearing benefit, and social support benefits can make a very big difference in millions of people’s lives. Those retirees often don’t have any other financial asset for those levels of services and care and those benefits can be life-changing for millions of people and they need to be protected — not attacked.
The chair of MedPac said he was concerned that high-income Medicare retirees would think that they were being treated unfairly by the current approach because they had to buy supplemental coverage from an insurance company and the higher income people needed to spend hundreds of dollars each month to get the same benefits that Medicare Advantage enrollees get for free.
He doesn’t mention or describe or explain the massive income differences for those sets of enrollees in his discussions or papers or include them in any of his agendas — and that’s odd because he seems to have some training as an economist that possibly got him named to that position as chair.
The clear and undeniable truth is that Medicare Advantage costs less — and it costs less because it’s delivering better care, and that’s an economic reality and economic relationship that the chair should understand, approve and support.
Diabetic care in the plans creates the lower costs that allow the 18% lower bids to be true, and we need people to know how that works and why it’s true.
All of the additional benefits that exist for the plans happen because the plans take that lower bid level and still create all of those benefits for the members with better care.
The additional dental benefits and vision benefits, and hearing benefits and special support benefits are completely and provably free to the Medicare program, because they’re paid for in the context of that 18% lower cash flow — and there’s no way of having any of those expenses for those benefits charged to the Medicare trust fund in any way because the capitation payment is the only expense for the actual Medicare program and that is a cost decrease instead of a cost increase for that fund.
The Additional Benefits Are Free to the Trust Fund
The critics and the people who do the MedPac report don’t want to admit that those additional benefits are free as an expense to the trust fund.
Once the capitation is paid, that expense has happened and it’s a done deal and closed book for Medicare for each of those capitated patients.
When the critics say that the nurses go into people’s homes to inflate the coding on the level of diabetic care that exists for a patient, and when they say that visits by those nurses into homes somehow increases the costs of the Medicare program, the answer is: The capitation can’t be changed after the fact to make that additional payment happen, so those activities and interactions are all actually irrelevant and the frequently repeated stories about those encounters increasing Medicare costs only serve to support fake news on that issue — and they have absolutely no impact on actual Medicare costs for those members.
We need to close the book on those issues.
We also need to get MedPac to grow intellectually and to somehow include one mention of process improvement in the delivery of care on their next report, because they’ve ducked that topic of functional care improvement by the plans completely, totally and entirely for decades and that’s extremely incompetent, inept, inappropriate, inadequate, intellectually inferior, and structurally and conceptionally dysfunctional for MedPac as a way of looking at that program and the costs of that care.
We need them to increase their competence in those areas.
MedPac needs to clean up its act on those data issues and should do it now because there is a massive opportunity now to move Medicare to an entirely new context for the politics of this country that can benefit everyone from every group if we do it appropriately, and if we use the real numbers and actual performance levels now.
We currently don’t need a political debate on the future of Medicare.
Medicare Advantage has saved the day. We should be looking at optimizing — not minimizing — our investments in Medicare now and we should be giving many millions of seniors much better benefits for their retirement years at lower costs.
We now have much better benefits for those members at a significantly lower cost, and we need Medicare to become a strength for the nation that helps us get better care everywhere as a result and be a model for the next generation of care.
Our national politics has had some very different perspectives from the two parties about the future funding levels for Medicare. The political people have been attacking each other about whether to fund Medicare at adequate levels.
That is listed as a top issue for several sets of contentions and situations.
The truth is that Medicare Advantage costs 18% less than the average cost of fee-for-service Medicare at this point in time, and Medicare Advantage is now a clear majority of the members — with 80% of the very lowest income members in plans — so we no longer need to bail out or protect Medicare in any way.
What we do need, is to keep the MedPac absolute absurdity — and total and shameless lie about that 22% overpayment number — from destroying the benefits for those members now, so that people get the coverage they need and so the trust fund is saved.
George Halvorson is Chair and CEO of the Institute for InterGroup Understanding and was CEO of Kaiser Permanente from 2002-14. Part 1 of this piece was on THCB earlier this week
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