Over the past 50 years, the Medicare payment system has evolved, and people who have chronic kidney disease have a real stake in understanding how it works!
In 1972, Congress enacted legislation allowing qualified individuals with End-Stage Renal Disease (ESRD) under the age of 65 to enroll in Medicare, the federal health care insurance program. This was the first time that people were allowed to enroll based on their specific medical condition rather than by their age.
As of 2021, people diagnosed with ESRD can choose either original Medicare or a Medicare Advantage (MA) plan for this coverage. Prior to that, patients were not allowed to enroll in MA plans because Congress believed these plans had inadequate provider networks. For example, if I needed a vascular surgeon for dialysis related care, but I had an MA plan with only a limited number of vascular surgeons that were in-network, but they had no immediate appointments, I would end up in the ER. In an MA plan you need to seek a referral before seeing a specialist, which can be time-consuming and inconvenient, and can lead to longer wait times.
MA plans–“managed care” or “value-based care”–are designed to control healthcare costs while improving the quality of care. In a managed care system, healthcare providers work together to manage and coordinate the patient’s care, overall health, and utilization of resources. Medicare Advantage is not Medicare, though the name can be misleading. When enrolling in an MA plan, patients choose a private insurance company to manage their coverage. MA plans assume the risk of the patient’s care for a fee from Medicare.
The U.S. Department of Health and Human Services, through the Centers for Medicare and Medicaid Services, finalized the rule to strengthen Medicare, expand access to behavioral health care, and crack down on “misleading” advertisements.
The managed care companies’ goal is to be more proactive, with methods such as eliminating duplication of services and assigning case managers to help patients navigate their health care. MA plans promote an integrated approach to care. By sharing and centralizing patient health data, managed care companies emphasize preventive measures to help improve the health of patients in their care. Such as stopping smoking, healthy eating, immunizations, and regular health screenings.
MA companies advertise via social media, television, radio, online and print media and direct mail. These advertisements may highlight the benefits of managed care services, such as lower costs, access to a network of healthcare providers, and preventive care options. Some companies provide incentives such as discounted premiums or co-pays, rewards programs, and free health screenings to encourage enrollment. They market their services in several different ways to get patients to sign up. If what they are saying sounds too good to be true, buyer beware! Do your due diligence.
Managed care companies work to reduce healthcare costs by negotiating rates with healthcare service providers. They renegotiate contracts every year with providers and vice versa. Some providers may not want to work at their negotiated rate. But here is the catch for patients: when contracts are not renewed, and providers switch in and out, patients may have to change their doctor, dialysis facility, or transplant center.
Something managed care does not always offer is continuity of care, which is very important in my mind. Anyone who has dealt with chronic illness over the long-term will tell you that staying with the same care team who knows and understands your condition is critical to survival.
Kidney disease is unlike any other illness. It is not just a hip replacement, a one-time procedure with no need for follow-up. We need continuous care, and relationships with our providers and facilities are vital to managing our health. In addition, some people have found that MA plans limit access to certain treatment options or procedures in order to control expenses, resulting in fewer treatment options.
To wrap up, MA plans can offer several benefits such as lower cost, but will limit you to a network of healthcare service providers they contract with that may not include your doctor, dialysis or transplant facility. Eligible individuals should weigh the pros and cons of managed care and consider what is best for their specific needs and circumstances.
Lori Hartwell is the Founder and President of Renal Support Network (RSN) and the host of KidneyTalk™ Podcast Radio. Lori was diagnosed with kidney disease at the age of two. She survived 50+ surgeries and 13 years of dialysis, and is now living with her fourth kidney transplant. In 1993 she founded RSN to instill “health, happiness and hope” into the lives of those affected by chronic kidney disease. Lori is also the author of the inspirational book Chronically Happy: Joyful Living in Spite of Chronic Illness and is a four-time kidney transplant recipient.
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