Lisa Young: I'm joined by Jonathan Cohee, CEO of Delta Health, to talk about the differences and similarities of Medicare and Medicare Advantage programs. Medicare Open enrollment for 2024 runs October 15th to December 7th. Mr. Cohee reached out to KVNF to talk about Medicare and Medicare Advantage programs. Tell our listeners why you think this is such an important topic.
Jonathan Cohee: This is a passion of mine. As the Medicare Advantage product was developed in the how it is marketed. Medicare Advantage spends a lot of money putting out the message about the advantages of Medicare Advantage. Even in that name, Medicare Advantage, it seems as if you get Medicare Advantage, you have a plan that is superior to Medicare. The traditional Medicare really doesn't market itself as such. So the reason I'm passionate is Medicare Advantage plans significantly limit the Medicare benefit for Medicare beneficiaries, benefit that they've worked their whole life.
You've worked your whole life to earn this right, to have Medicare benefits and as soon as you sign up for a Medicare Advantage plan, it really limits the types of services that you can receive, the providers that you can go to and then now you have to get authorization for services that you really shouldn't have to. Those are services that you've earned. So that's really why I'm passionate about it, is it's really the limitations in really the shell game that it plays with seniors. That's why that's why I want to be here today.
Young: My understanding is that Medicare itself is run by the government, but Medicare Advantage plans are more run by the insurance companies. Do I have that right?
Cohee: Correct. So the insurers and I'll just pick on a couple of just to give you examples like Humana. They have a Medicare Advantage product so, most of the major insurance companies have a Medicare Advantage product and they were created to help Medicare manage the Medicare population. The reason that they were brought together was (but it was the insurance companies that were able to form the rules behind Medicare Advantage) which is that's another story in and of itself.
But the reason that the Medicare Advantage plans were born was to save Medicare in Medicare dollars. And in fact, if you look at the literature, Medicare Advantage is actually continues to cost ...for every dollar that it would cost the United States for a Medicare patient. It actually costs you a dollar plus for the Medicare Advantage. There hasn't been the savings.
Young: It sounds like the hope was that there would be a savings to the entire Medicare program, but it sounds like that really didn't happen. So I guess, and this may be a question for someone else, why do we keep doing that if it really isn't saving money?
Cohee: Maybe a politician can help to answer this. It really doesn't make sense and I understand trying to put something in place to save money. I'm a therapist by trade so make a treatment plan and I assess that treatment plan and after three treatments, if it's not working, I reassess that and I have to change that treatment plan. Same thing here.
I think that all great intentions, Medicare Advantage was created to help manage our Medicare population and actually produce a savings, but it really has not produced the savings that it was created to produce, and it really limits the types of services that our seniors are afforded.
Young: I want to talk a little bit about that. Maybe give me a little bit of a case scenario where someone comes in and they purchased Medicare Advantage because they saw that there were some added benefits, some things that were added to the plan that looked really enticing to them. There was a cap maybe on their annual premiums, something to that effect that brought them in to Medicare Advantage and now they have a situation where they need a provider and they they think they're going to be able to have that provider here locally. Walk me through what something like that might actually look like.
Cohee: So I appreciate it, because you said a lot in that and and I'm sure we'll touch on different pieces of it because you are promise with Medicare Advantage. One of the reasons I may sign up is that I'm going to get a decrease in my premiums because I'm on a fixed income and so I may get a decrease in my premiums or when I go to a if I see CVS, I should say Walgreens and I should say insert insert store here. But if I go to that store, I'll get coupons. I may get a free pair of sneakers, I may get a free bottle of lotion, I may get free shampoo like every month. So that is enticing in and of itself and that's really how they lure people, lure people in, because I don't get a free pair of sneakers.
I don't get a free bottle of shampoo or free lotion if I sign up for traditional Medicare.
So I've made that choice to sign up and let's say for, heaven forbid, I fracture my hip right and the the services that you provide, the providers that you are having to go to, I want to go locally here. I want to go to Dr. Knutson. Dr. Knutson and and his team are amazing. And Dr. Knutson may not be on this Medicare Advantage plan. So you have limited providers and because you're on a Medicare Advantage plan. That Medicare Advantage plan drives where it is that you should and will receive your services.
So you may have to drive (to receive care). This may be a little bit dramatic, but it's not. It happens. You have to drive out of Delta. So maybe that planning has to make you you have to go to Junction or maybe there's such limited providers that you may have to go to Utah or go to the Front Range and go to Denver because that's where my providers are located add you also then have to have prior authorization to be able to receive those services.
Cohee: So you have a fracture or some other kind of injury or some other kind of illness that you need to receive. Whether it's an MRI. Should be simple. A CT scan, and you have to have prior authorization before you can receive the services. So there's a delay. There's a delay in treatment and then there's also the burden on you because you have to travel.
There is that burden to travel. So you can imagine you're not feeling well. I mean, who wants to go to the hospital? Who wants to go to the clinic? You just don't. I go get my Well Check and I'm good and I'll see you in a year, right. That's how I love health care and it. But if I'm not healthy and I have an issue, I need to be able to go and want to go where I can go and that's the issue with the Medicare Advantage plan it delays, treatment, and then often denies different levels of care.
You may have the ability to go just receive therapy to get through your your illness that may be denied or delayed. And it's really just that limitation of services and that authorization process. That's really the piece for when I say traditional Medicare, you've earned that right. You've earned that right to be able to go to providers that you want to go with you. You've earned that right not to have to wait for prior authorization to receive a service to your primary care.
Cohee: Doctor says you need to go here or you're in the hospital. You need to go here. If you have inpatient rehab, stay after your fracture. Right. You need to be able to go have that if you've had a stroke and you need to go to receive this special specialist service before you go home, you need to be able to do that. I don't want that specialty service denied and then I have to go to skilled nursing facilities are fine, but you have to go to a skilled nursing facility because it's a cheaper level of care. And so you're sacrificing and limiting the services that you should be able to receive and you've earned.
Young: Which leads me to my next question, as far as Delta Health and your clinics, your your Medicare, anyone with the original Medicare can have services here. What about Medicare Advantage? Are you a part of that? Will you get reimbursed if someone comes in with Medicare Advantage? Are you in network or out of network?
Cohee: We are in network with a lot of the Medicare Advantage plans.
If they say Darnell (Place-Wise, Delta Health Public Information Officer) has Medicare. If she goes in to see a see Dr. Freese. Dr. Freese says that Darnell has to go across and get some labs or you need to get an MRI. Darnell can go as long as our scheduling system works the way that it should, she'll get that MRI rather quickly.
I come across and I have a Medicare Advantage plan, and we participate in the Medicare Advantage plan. But because it needs prior authorization, even though I'm an authorized provider with this Medicare Advantage plan, I have to wait. I have to wait an average of 7 to 10 days for that authorization to be processed to receive my MRI.
Young: Who does the authorization then? It sounds like it's not somebody who's a physician it's someone in an office looking at codes or help me understand how this works.
Cohee: In this Medicare Advantage plan, they typically you'll have a script, right? In this case, we're using Darnell. It's okay to use you, right? She needs this MRI, and I go through my script and says, okay, Darnell needs an MRI, I'm going to okay this MRI. But they have their 7 to 10 days, right? So they wait there. And then they may or may not allow that. And it's usually you based on medical necessity.
If Darnell has a really good reason to get that MRI in the doctor's notes are really clear and spells out exactly why they need it. So it's really for a diagnostic thing. It's not like a nice to have, you know. So for example, to say Darnell has this pain in her hip and really wants an MRI, the doctor says, "Yeah, I agree, you should have an MRI. We want to see what's going on".
The Medicare Advantage can look at that and say, well, this really isn't a really good medical need. I need some more detail. So we have to go back to the physician's office to get a more detailed reason to get the MRI. If Darnell had Medicare I mean, the physician is going to order the test if they don't need the test.
So the providers will order that if they need it and they won't if they don't need it to go right to the MRI. So there's delay. And some of that delay is, one, the hope that people will get frustrated and then just don't have it and then they don't have to pay for that. But it's so it's a service that they provide, quote unquote. And they don't have to actually pay for that service because they just delay or they limit, which makes it more difficult to receive the care in hopes that there'll be an exercise in futility and people just won't receive the care.
Young: Yeah, it's like a single layer cake or like your carrot cake with multiple layers, which I love carrot cake, by the way, which I would eat any day of the week, but not when it comes to your your medical services. By the way, we should note that this is Darnell Place-Wise Public Information Officer here for Delta Health sitting in with us today. Always great to have Darnell riding along with us.
So if you get a doctor who says you need to have a procedure done and then it has to go through Medicare Advantage for them to approve that 7 to 10 days and then once you maybe you do or do not get that approval. Let's say you do get it, then you've got to go through the scheduling process. It's just adding a lot more time and actually it's adding more potential money out of your pocket if they say, "Well, we can't do that here because that provider's not in your network, you will have to go to Grand Junction or maybe even over on to the front range".
Young: That's a lot of time and that's a lot of money. I'm really hearing that you're not a fan of Medicare Advantage for these reasons that you listed. What else can you tell us about it and who qualifies and what more do they need to know about their choices?
Cohee: So 65 years use of age to be Medicare eligible. So (if I)receive my Medicare benefit. I've earned that and nobody should have the right to kind of take that away from me. So no matter what you bring to me, the message I want to hear today is keep that benefit, that Medicare benefit that you've earned. It's not limiting. You do not have a limitation with providers. You don't have a tedious prior authorization process. You don't have a need to have a referral to see a specialist.
So when it comes down to comparing the plans, you'll receive a lot of information and at times it's 8 to 10 pages. I think the document that I have from the Colorado Health Care Association, I think that they did a really great job of comparing Medicare versus Medicare Advantage. but the document is eight pages. Right. And so it can get confusing.
So the message is simple. If you qualify for Medicare, you're 65 years old. Keep your traditional Medicare. Medicare Advantage looks really cute, right? It's got a nice bow. It's got some free stuff thrown in there. I'm on a limited income, so the premium might be a little bit less per month, but all that glitters is not gold, right?
Medicare Advantage plans are set up by insurance plans to limit your benefit. How can they manage that? How can they save money? If I restrict your services, I the insurance company, I'm going to make money. Medicare is going to pay me to take care of you. And if I limit your service, I get to keep that money that Medicare pays me, the insurance company to to service you.
How do I do it? Make the prior authorization process tedious. I limit the specialty providers that you can see and I just make it hard, right? Traditional Medicare doesn't make it hard. You receive the services that you need when you need it, and then also the hospitals.
Cohee: And on the flip side, the hospitals, the physicians, the providers, all of the health care providers get paid quickly for the skilled services that they provide. And so they're able to keep the hospital open. So there's not there's not really a game. You know, seniors need the service. Health care institutions are able to provide that service, get paid for that service, keep the doors open and then it's just a nice rinse and repeat cycle that helps keep our seniors well and happy and satisfied. And you just really can't do that if you have a coverage that's tedious.
Young: I think we could call this discussion just getting through all the noise and getting to the main message, which is when you qualify for Medicare at 65 or if you have some kind of a disability, a lot of folks who've had renal failure will qualify as soon as they can get that medical determination. Other folks with disabilities can also qualify before age 65.
The simplicity of this message is: you have what you need in Medicare and you can just go with that and feel confident that you'll get everything that you need through the medical services that you earned, as you say, versus Medicare Advantage.
Cohee: Absolutely, keep it come October 15th when they're doing the enrollment, everybody's getting information everyone is forcing you to make a choice. You know, have to make a choice. Keep your traditional Medicare. You're not under the gun every October 15 to make a choice, keep your Medicare benefit. It is really what's going to serve you even if you're feeling well.
Plan for tomorrow was tomorrow look like what's next week look like. You need to have the service available when you need the service. The great thing would be you go from 65 to 66 and you don't need the service. You get your well check, you will visit in your good, you see your provider. Please make sure that you see your provider at least once a year to get your checkup. But once you do that, you're good. And hopefully you go from 66 to 67 and you don't need it. But when you do need it, you need the service. You don't need anybody else telling you what you need and what you don't need. Your providers will work hard to get you well and you need your providers to be able to give you that service and you'll be able to stay local to to receive those services.
Young: It definitely seems like from the physician side of it, the person who's providing your care, would really probably say the same thing because they want you to get what you need as soon as you can get it versus having delays or frustrations or having to travel for procedures that could be done locally. So I think most doctors and of course, we're not here to speak for them, would probably say the same thing.
Cohee: Yeah, we're sitting across from enough of those and my wife being a nurse practitioner, I just know that it's really nice from a provider standpoint to not have that limitation. So if I want a specialty service to take a look at my patient, I need that. I need that expertize as a provider to be able to say, "Hey, here's what I see. Do you see the same thing?" Because this is all that you do. So for me to have to pivot or to want to do something else, because that's not that's not available because of the insurance plan that you have. That's frustrating and it's also it's it just doesn't help day in the day. It doesn't help the patient get what they need when they need it.
Young: Yeah. And if you already have Medicare, I qualified for Medicare because renal failure had a kidney transplant. So I've had Medicare for almost ten years now and I've never, during the open enrollment, paid attention to anything because I'm rolling on with Medicare.
Cohee: You have traditional Medicare, you just keep it. You don't have to make a choice to go to another plan. Keep it simple. If you need help, you can call our team. Our team here at Delta, we'll make sure that you get the information that you need, that your best choice is no choice. Just keep your traditional Medicare. You've worked really, really hard your whole life. Keep that benefit and keep the choices in your pocket rather than somebody else making those choices for you.
*** Disclaimer: Before making any decision on Medicare Enrollment be sure and check with Medicare, your insurance provider Or contact Delta Health at (970) 874-7681.
