ASC and spine leaders are increasingly concerned with Medicare Advantage, citing prior authorization denials and slow payments.
Here are five leaders' recent thoughts on Medicare Advantage:
Harel Deutsch, MD. Co-director of the Rush Spine Center (Chicago): [Medicare Advantage] has gotten much, much worse [than it was a year ago]. It was bad back then, but now it's five times worse. Every time I turn on the TV, I see ads for Medicare Advantage and basically Medicare Advantage, they'll disapprove any surgery you apply for. A lot of times I have to tell patients, look, you have to wait until you can unenroll and then do that. Then you can have your surgery.
Brian Gantwerker, MD. Neurosurgeon at the Craniospinal Center of Los Angeles: We currently are no longer accepting Medicare Advantage. The restrictions regarding these plans have made taking care of patients extremely cumbersome. Even routine studies are denied. I had a patient I met when on call with an odontoid fracture. I fixed the fracture by fusing the first and second vertebrae together from the back. Her plan denied a follow-up CT scan, which is routine, at six months. The plan denied the scan because she "did not have a spinal cord injury." We appealed because: 1) The whole reason I did the surgery was so she wouldn't get a spinal cord injury; and 2) The proper study for a spinal cord injury would very likely be an MRI, except in certain situations. Either way, the denial was ridiculous. If you couple that with payment issues — late or no payment all, along with increasingly uncovering the money-making scam MA plans have turned out to be — taking these plans becomes a losing option. I feel for the members and encourage them to talk to their insurance agents, or in some cases, their human resources people to seek other options. Many hospitals have also stopped taking them altogether. The unfortunate truth is that the companies offering these plans and TV commercials mislead patients into thinking they are doing the right thing. The patients lose by giving these for-profit companies their hard-won Medicare benefits while the companies don't pay anyone who is giving care. It's a scam whose end time has come.
Andrew Lovewell. CEO at Columbia (Mo.) Orthopaedic Group: With the inflationary curve on the rise and another looming cut to the physician fee schedule, it is imperative that we re-examine our payer contracts with all other payers in our market. Many of the Medicare Advantage plans in our market are trying to pay below the Medicare physician fee schedule, and none of them are accounting for the implant costs associated with doing surgery in our ASC. I am also looking for steerage from the payers for ASC strategies in our market. As the low cost/high value provider in the market, we should see significant streerage to our facility but have not experienced that yet. With our clinical outcomes both surgically and non-operatively, we are the best value around.
Patrick McEneaney. DPM. Owner and CEO of Northern Illinois Foot & Ankle Specialists (Crystal Lake): The healthcare trend that I'm most worried about in 2024 is the increasing number of patients who are signing up for Medicare Advantage Plans. I have found that my most vulnerable patients are picking up these plans. These are patients who have multiple comorbidities, are at high risk for exacerbations of their medical conditions and/or those who have insecurities with their socioeconomic situations. These plans are touted by brokers promising extended benefits and significant cost savings. However, the savings are often only on the front end of the program at the time they sign up. Many patients don't realize that these plans may have copays, coinsurance and deductibles, which often cost the patients more in the long run. I see patients skipping visits, treatments or diagnostic testing in fear of the costs associated with these plans, which leads to poorer outcomes. The aggressive advertisements and monetization of these patients' lives to brokers' commissions have led to a significant amount of misunderstanding from patients.
John Prunskis, MD. CEO and Medical Director of the Illinois Pain & Spine Institute (Elgin): Maybe you should call them 'Medicare Disadvantage' plans… If you want to take control of yourself, invite your Congressman to your surgery center and show them the cost savings, they'll probably know about that, but then explain to them the Medicare Disadvantage plan is actually profiting off our taxpayer dollars to not provide care to seniors that they're supposed to.