Opinion: The siren call of Medicare Advantage

A page from the 2019 U.S. Medicare Handbook.

A page from the 2019 U.S. Medicare Handbook. AP


Published: 11-25-2023 6:00 AM

Robert S. Kiefner, MD, lives in Concord.

This year, just over half of Medicare beneficiaries will be seduced by the sirens of Medicare Advantage advertising. According to Greek mythology, the sirens (creatures who were half bird, half woman) lured unknowing sailors to their deaths upon the rocks with the sweetness of their songs.

The Greek hero Odysseus, upon the counsel of the sorceress Circe, avoided disaster by plugging the ears of his crew with wax and by strapping himself to his ship’s mast so that he would be able to hear the song, but not steer his ship onto the rocks.

Though the relentless advertising din is more of a cacophony than sweet music, in this silly season of Medicare enrollment, Medicare Advantage advertisers and enablers are beckoning potential buyers with often false promises of free dental and vision benefits, free food, free medications, free transportation, etc. We would all do well to plug up our ears or strap ourselves to a mast.

In fact, Medicare Advantage is not true Medicare. It is private health insurance which is absurdly over-subsidized by the government. As such, it incorporates into its business plans soul sucking pre-authorization protocols, widespread denial or delay of care, restricted provider networks, and an array of surprise co-pays. Indeed, the business model for Medicare Advantage is as seedy and deceitful as they come.

Advocates for managed care and MA offer tiresome and blatantly inaccurate claims that MA plans reduce costs, improve quality of care, and facilitate consumer choice. The independent Medicare Payment Advisory Commission (MedPAC), charged with advising Congress on the Medicare program, revealed in a report of June 2023 that beneficiaries with similar degrees of illness ended up costing 11% less in traditional Medicare versus MA. MedPAC has never reported better outcomes among MA patients while acknowledging that the burdens of preauthorization and precarious provider networks so common with Medicare Advantage plans are not widely reported with traditional Medicare.

Medicare Advantage plans not only make money by withholding care but, perhaps more significantly, by misrepresenting the severity of illness among their beneficiaries. MA plans are paid a monthly fee by the federal government based upon a patient’s level of illness, known as risk score. It has been well established that, through advertisements (hawking free gym membership, dental care, etc.) directed towards healthier people, these plans enroll patients who are generally healthier, thus spending less in the aggregate.

But, hold on, here’s where they really pick the taxpayer’s pocket. MA providers often upcode patients’ level of illness to make them appear sicker than they really are, or even fabricate nonexistent illnesses. On the positive side, the Dept. of Justice has caught on. Virtually all major MA insurance providers have been fined by the Dept. of Justice for violation of the False Claims Act. This fall, Cigna is on the hook for $172,294,000 in fines, while the quaint and adorable sounding Martin’s Point MA plan out of Maine will need to cough up $27,485,000 for similarly bad behavior.

Fines of this magnitude reveal just how profitable MA plans can be, since the insurers seem to write off the fines as a cost of doing business. Additional fines are being assessed upon insurers by virtue of their practices of using AI algorithms to systematically deny claims of MA beneficiaries who are struggling to recover from serious illness in nursing homes. The behemoth insurer United Healthcare was recently named in a class action lawsuit in the U.S. District Court in Minnesota for this practice. Thus, insurers are constantly running afoul of the law and corporate ethics (oxymoron?) in the course of doing business.

In a paper released by Physicians for a National Health Plan (PNHP) last month, reported overpayments to MA plans totaled between $124 and $140 billion in 2022. A Congressional Budget Office analysis in 2019 concluded that the addition of dental, hearing, and vision benefits to traditional Medicare would top off at $84 billion.

By funneling tens of billions of dollars each year into the black hole of for-profit business, do we really improve care? Nope. As a nation, do we need or benefit from for-profit health insurance companies in general, and Medicare Advantage plans in particular? Not in the least.

With a desperate need for bipartisan budget discussions in Congress, the elimination of tens of billions of dollars of unnecessary subsidization of insurance companies would seem to be low-hanging fruit. The failure of our country to adopt truly universal health coverage is directly attributable to complexity, nefarious by intent, on the part of insurers, Big Pharma, pharmacy benefit managers, mega-hospital groups, and pharmacy chains among others. And they are aided and abetted by a Congress which listens to the deceptive appeals of moneyed lobbyists and the hierarchies of wealthy healthcare influencers.

It is now the entrepreneur, pushing “disruptive” schemes in healthcare to maximize profit, who have supplanted the role of the physician in determining care. We spend twice as much per capita on healthcare than any other nation, yet we are mired in mediocrity when it comes to access, outcomes, and patient satisfaction.

As enrollment deadlines loom and insurers clamor for attention, we should follow the lead of Odysseus’ crew and use earplugs to block the sound of sirens, to avoid their seductive songs, to keep the hope of universal healthcare alive, and to keep the ship of traditional Medicare from crashing upon the rocks.