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Medicare Advantage: When insurance companies make house calls

December 16, 2015
  • By Beverly Merz, Executive Editor, Harvard Women's Health Watch

About the Author

photo of Beverly Merz

Beverly Merz, Executive Editor, Harvard Women's Health Watch

Beverly Merz is Executive Editor of Harvard Women’s Health Watch, a publication she helped start in 1993. Before coming to Harvard she was an Associate Editor of JAMA, Managing Editor with the Union of Concerned Scientists, … See Full Bio
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December 18, 2015

Exactly right!! It is very disconcerting that we pay for Physician care and expertise, but in the end, the insurance company decides what is best for us.

December 18, 2015

If an insurance company wants me to waste an hour of my life to help them make greater profits, they’re going to have to offer me more than a $25 Walmart gift card! I’m thinking an hourly rate of, ooh say $1000 might be more reasonable. What is it worth to them? The higher HRA score must give them a big financial bump, since they are spending the money to hire an NP or physician to drive around and do house calls on weekends! As for the Walmart gift card, I’d love to know if Walmart gives these to the insurance companies for free (as a loss leader to get people in), or if they are given at a discount rate or with some other kickback arrangement between Walmart and the insurance companies?
In the end though, what a waste of time and money, duplicating services, confusing the patients and their physicians, and possibly causing harm by making extra unnecessary diagnoses, leading people to think they are sicker than they are, creating psychological distress and creating more people who are the “worried well.” First do no harm – that is more important than increasing insurance company profit.

Maribeth Miles
December 17, 2015

Big Pharm/Big Insurers are making mucho dinero courtesy of Obama and his fraud-based scheme. Shame on our legislators but special shame o Mr. Obama who had the opportunity to implement Medicare for all/single payer and instead perpetrated this!

December 17, 2015

Seriously! Are you telling me that he could have pulled off single payer? He almost came up totally empty. He got something, despite the odds. Republicans must have discovered that the sky didn’t fall. Life continues after Obamacare. Next step : cut out the middleman, insurance industry.

Peter Brewster
December 17, 2015

Dan’s comment sounds to me like justifying a search for positives by way of unsolicited income-yielding exams. You’re bound to find some positives – especially if you’re not looking for negatives. Dan’s MA reflects too much bean-counter influence and too little thought-out health care interest.

December 16, 2015

This is a very nice summary of the Health Risk Assessment (HRA). For full disclosure, I do work for a Medicare Advantage (MA) plan. I just wanted to clarify one aspect of your “what to consider” summation. You state, “If you are healthy and the visit results in an increased risk score, you won’t have to pay more for your care. But the higher Medicare reimbursement your insurer receives may contribute to the nation’s rising health care costs.” This is not a completely accurate statement. True, the MA enrollee will not pay more in premium and cost-shares in the current plan year, but based on the plan’s financial performance, unidentified conditions will lead to lower reimbursement to the plan from CMS than they are otherwise entitled to, which leads to higher Medical Expense Ratios (cost paid-out in claims for every dollar in revenue). As the MER increases, along with increasing medical trends, the plan is forced to increase premium and/or member cost share, or remove additional coverage like comprehensive dental or vision benefits not covered by Medicare in subsequent years. Identified or not, the condition will eventually impact the national cost of care. So, I propose your statement is incomplete and misleading. For every unidentified risk factor, over time, the members cost will go up and will still contribute to “the nation’s rising health care costs” regardless. There really is no down side, other than perhaps 45-60 minutes of your time, to receiving an in home Health Risk Assessment (of which in many cases the plan rewards you for as you indicated in the gift card offer). Also note, the HRA doesn’t have to be completed in the home. It is actually more economical for the plan if the HRA is completed in the Primary Care Physician’s office (the physician is often compensated for the extra time it takes). This is something your provider should be doing anyway. I do not know what insurance carrier your MA plan is with, but when they called you, they should have given you the option to have an in home assessment or schedule an assessment at your doctor’s office. This should be completed every year. In fact, conditions identified in one year do not carry over to the next. For example, an amputee identified as such in one year will increase the risk score. However, unless the HRA identifies the missing limb in subsequent years, CMS assumes the limb miraculously grew back and the score will adjust down. MA plans are not trying to scam the system. They are simply trying to identify all conditions to maximize the Risk Score so that CMS pays the appropriate amount for each Medicare enrollee’s care, no more, no less. This also allows the plan to identify and encourage better care management plans that can lead to better quality of care and quality of life as well as help prevent more costly treatments and care like hospital stays etc., which will in turn help minimize “the nation’s rising health care costs.”

December 18, 2015

The insurance company also should have been honest, open, and forthright about WHAT they were doing, and WHY, including their financial interest and potential benefit. Starting out of the gate with omission of these facts is shady and deceptive.

December 18, 2015

It is also not the insurance companies’ job to “identify and encourage better care management plans.” What a load of hooey – that is the primary physician’s job, not an insurance company’s job! Insurance companies flood physician fax machines with useless “helpful suggestions” that are ridiculous and waste time and mental energy – not to mention ink and paper – I’ve seen it! If insurance companies stopped playing physician, and stopped creating extra busy work for physicisns, then physicians could have more time to do their own jobs! It’s backwards now, with insurance companies trying to practice medicine, and physicians being forced to play at being paper pushers!

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