Fixing Medicare Part B - WHAT WOULD YOU DO?

[GailL1]

  We pay for Medicare Part B or SMI Insurance (Supplemental Medical Insurance) by premiums which are either paid or deducted from our Social Security Benefit.  The amount we pay in premiums are based on our income.  Lower income beneficiaries have their premiums paid for them by their state if they meet the eligibility guidelines in income and assets; therefore these lower income beneficiaries actually have their premiums paid by YOU, the state taxpayers.  The majority of beneficiaries pay a premium that is equal to 25% of the cost of the program.  Higher income beneficiaries based on their higher income pay a premium that is higher in a percentage of coverage from 35%, 50%, 65%, 80% to 85% of the program cost instead of the standard 25% (these higher premiums are known as IRMAA or "income related monthly adjustment Amounts and these are very high.  

The remainder of the Part B cost are covered by our government's general fund - meaning it adds to the debt of our country.  

Those who have a Medigap plan are somewhat protected from their part of the out of pocket cost of Part B but as cost rise in usage, these medigap premiums will also rise.  

Medical cost continue to rise year after year - and so do our premiums for Part B.  These will continue to go up and up based on this method of paying for Part B.  However our country's debt is now getting out of control so how long will it be able to cover the part that is paid from the General Tax Fund?  

Medicare Advantage plans are paid a set amount for their coverage of Part B expenses.  They are able to use various approved managed care methods to keep their cost in line - things like prior approval to prove medical necessity for a particular treatment or a step-therapy method to try the lower cost treatments before covering the higher cost treatments.  

We have nothing like this in the Traditional Medicare program although claim review does take place and traditional Medicare can also exert a prior approval method for certain care and also question the medical necessity of other care.  But for the most part, if it is a covered benefit, then most likely it will be approved under Traditional Medicare.  

So what are we to do to control these Medical cost and in turn keep down our premiums but a more important concern is how do we control what is being added to our country's debt from Part B cost.  We are now getting to the point of being between a rock and a hard place.  Can we do something before the bottom falls out from under us?  

I don't think cutting doctor fees is a solution anymore if you want to keep the docs enrolled in Medicare.  The "rich" are already paying more so that's already done.  We could move to a whole managed care program where the whole program is more scrutinized in benefits given - but that does not seem popular.  

How much more are you willing to pay in Part B premiums to take more of the cost off our fellow citizens in their taxes?

[CBtoo]

Of fthe top of my head: I'd start with not giving Advantage Plans more money than traditional medicare gets. That would save some money. I'd add dental, vision and hearing aids to B since those with original medicare don't get that (advantage plans already get that however the extent of those benefits with respect to what they cover is falling). Yes we'd have to pay more but those are important to our physical and mental health. Or give us a B with and without that (that being said a Costco membership means hearing aids are half price) and let us choose.

I'd limit the amount of profit a company that offers advantage plan can make off of advantage plans (I know you only asked about B and people have to buy B with advantage plans anyway the same way that is the rule for employee insurance - 80% of the premium money has to go to pay for medical care and if less goes then the members need to have that refunded or it is required to be used to adjust the following year's premiums), 

[WebWiseWoman]

My first thought is I would re-write the "Affordable Care Act". When I first read about it I thought it was to address the exorbitant costs for every procedure; as I was obviously wrong, I now know it was somewhat a tool of the health care and insurance industries for gain.

[GailL1]

@WebWiseWoman 

Now that is funny what you thought about the ACA.  But you are wrong about medical inflation - this is like any other type of inflation.  Medical inflation also happens because of usage.  If we all had auto insurance but there was never a claim, then the cost nor the premiums would rise for auto insurance coverage.

Cost rise for all businesses - a lot of it has to do with government regulations.  People want higher pay for the work they do - be them a doctor, a nurse, a pharmacist, a PA or NP - when that rises, so does the cost of their employment - workman’s comp insurance, unemployment insurance, professional insurance.

Then there is the cost and development of drugs and medical devices - very expensive.  

The best way to keep down the cost of medical insurance of whatever type is not to use it or only use it when absolutely necessary with perhaps some splurging of preventive care.

Private insurance companies have ways to hold down their cost and premiums - they can set prior approval standards to prove medical necessity, they can establish step therapy - where you try the least costliest treatment or med to see if they work before advancing to the more costly.  Quantity limits are used in medication mostly.  There are several uses for quantity limits - safety, waste, addiction prevention.  But even in other areas, there is a need for limitation - like how many days in a skilled nursing facility should produce enough recovery or expected recovery to be dismissed from this level of care.  A lot of people push this under Medicare Part A because they are old and neither them or their family have made any arrangements in pay or care for somebody to be there to help them for a while.  

If you want to control health care cost, we can look to what they do in other nations to hold down cost - but I do not think you would like some of what they do.

[BalbonisMoleskine]

Doctor fees could be cut further if the feds also require all doctors to accept a certain amount of Medicare patients as a condition of licensure. 

Would more doctors retire early as a result? Sure. They could be replaced by doctors from Canada, the UK and other countries where salaries are much lower, thus making the US an even more attractive place to work. 

Average physician compensation in the U.S. and 10 additional countries: 

U.S.: $352,000 

Canada: $273,000 

Germany: $160,000 

United Kingdom: $122,000 

France: $93,000 

Italy: $64,000

Spain: $60,000 

Brazil: $48,000

Portugal: $44,000

Argentina: $21,000

Mexico: $19,000

https://www.beckersasc.com/asc-news/physician-compensation-in-the-us-vs-10-other-countries.html#2

[GailL1]

Looks like the doc fee cut is in place to proceed - that makes it an over 6% cut in the last several years.  Yep, docs are upset - what do you think they will do?  anything?

[GailL1]

@BalbonisMoleskine 

I think you are probably talking about specialist - certainly not for primary care physicians like family docs, internist, primary care or general practice.  

And I don’t think we can tell docs how many patients with a specific insurance type they have to take - we can’t even tell them to accept Medicaid.  

Not as a condition of licensure or any other DEMAND.  

Under Medicare FFS, CMS sets the reimbursement rates for specific covered services and bundles those that are paid together.  There is already about a 3% proposed cut in physician pay for next year - it came from last year.  Especially at a time when we desperately need MORE primary care.

Got any other solutions for our premium problem with Part B?  

One of mine would be that we do away with self-referral to a specialist in Traditional Medicare.  Let the primary care doctors do the referrals if needed.  This is the way it is in most other countries with a single payer system.  Some thing just don’t need a specialist care or a higher price tag just because they are a specialist .  Primary care docs can handle a lot of different things.  

[TRL1111]

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@GailL1 wrote:

One of mine would be that we do away with self-referral to a specialist in Traditional Medicare.  Let the primary care doctors do the referrals if needed.  This is the way it is in most other countries with a single payer system.  Some thing just don’t need a specialist care or a higher price tag just because they are a specialist .  Primary care docs can handle a lot of different things.  

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I would hate that because I don't have a primary care physician.  One of the luxuries of having a supplement is that I can go to whatever doctor I want on the rare occasion I do go to a doctor--for me, it's whoever can get me in the soonest.

And I have personal experience with someone who went to an ENT instead of a PCP for sudden hearing loss in one ear and got a prescription for cheap steroids, and his hearing fully returned a few days later.  Meanwhile, others who have gone to a PCP instead of an ENT have reported that the PCP was unfamiliar with the condition and didn't prescribe the steroids, and they permanently lost their hearing because of the delay.  That's tragic.

And it's obviously just one situation, but it makes me very grateful that I can afford a supplement under the current Medicare scheme.  But I suspect all Medicare will become Advantage at some point--the government will just offload it to private insurers.  I'm just hoping it's later rather than sooner.

What I'd like to see a lot less consumption of medical care when somebody's at the very end of their life.  That's a huge waste and makes very few patients and their families happy, but they do it anyway.  

[GailL1]

In many other countries who have universal or single payer systems, people are required to have a PCP - they are the gatekeepers.

Also many of the new CMS models are promoting the use of PCP’s more and more - like for ACO’s.  In fact, in some places they will even accept a PA or NP to act in their place - medical infrastructure deserts.

Of course, there are always good, better, best and it is always up to the beneficiary to pick the PCP that they trust.  I have an absolute great one.  He will treat me when he feels confident to do so or orders test /images to figure it out but he will also refer me to a specialist if need be - like last year, diagnosed with Benign paroxysmal positional vertigo (BPPV) - and had to have treatment to get rid of it - which might come back but the treatment although long and uncomfortable did work.

Yes, with all the cuts in the FFS pay rate, some docs may reconsider how many patients they see on Trad. Medicare, especially since there are getting to be so many of us.  

[BalbonisMoleskine]

According to https://www.aarp.org/benefits-discounts/members-only-access/info-2025/where-are-all-the-doctors.html, the average primary care physician in internal medicine, geriatrics, pediatrics or family medicine makes about $250,000 to $275,000 a year.

That's an average, meaning a lot of PCPs make over $300,000.

PCPs and specialists alike will have to accept less. There's no other way around it.