Medi­care Ad­van­tage net­works raise pa­tient-provider is­sues

Modern Healthcare - - COMMENT -

Re­gard­ing the Sept. 28 ar­ti­cle “Medi­care Ad­van­tage plans need bet­ter net­work ad­e­quacy over­sight: GAO” (, Sept. 28), I have been fol­low­ing the de­bate on the changes in Medi­care Ad­van­tage plans, es­pe­cially in light of the en­act­ment of the Af­ford­able Care Act. Although data show that the num­ber of pri­vate health plans and their en­rollees have been in­creas­ing over the past few years, I agree that there is a need for more over­sight, es­pe­cially in the con­text of pa­tient-provider per­spec­tive.

In ad­di­tion to hav­ing a net­work broad enough to cover their med­i­cal needs, I be­lieve Medi­care ben­e­fi­cia­ries should have the right to choose which provider they would like in­volved in their care. Too of­ten, I hear of pa­tients who have been with the same physi­cian for decades but now have to stop see­ing this provider, end­ing a strong re­la­tion­ship sim­ply be­cause the doc­tor isn’t part of a plan’s net­work.

Nowa­days, the ra­tio of HMO ver­sus PPO plans un­der Medi­care Ad­van­tage is largely weighted to­ward HMOs. The PPO premi­ums are of­ten twice as costly. Thus, ben­e­fi­cia­ries of­ten feel forced out of their pa­tient-physi­cian re­la­tion­ship be­cause of their in­sur­ance plan.

Medi­care Ad­van­tage should ex­pand their provider net­works, while pref­er­en­tially in­clud­ing lo­cal providers who al­ready have a re­la­tion­ship with the plan’s en­rollees. In this sce­nario, it wouldn’t be nec­es­sary to con­sider whether a provider is tak­ing new pa­tients or not. Also, there should be a rig­or­ous re­view of the rea­sons for and im­pli­ca­tions of ter­mi­nat­ing an agree­ment with an al­ready-es­tab­lished provider, keep­ing the best in­ter­ests of the pa­tient in mind.

With the grow­ing con­cerns over the sched­uled re­duc­tion in pay­ment to Medi­care Ad­van­tage plans, I am cu­ri­ous to see how this net­work prob­lem will un­fold.

Michael Os­nard Master’s in Public Health can­di­date Univer­sity of Pittsburgh Grad­u­ate School of Public Health

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