Medicare vs. Medicare Advantage ~ Sicker Patients Tend to Opt for Original Medicare

Medicare vs. Medicare Advantage ~ Sicker Patients Tend to Opt for Original Medicare

Medicare Advantage plans are enrolling more and more beneficiaries with their attractive premiums and advertised “comprehensive and coordinated” care all in one place. In fact, currently 1 in 3 beneficiaries are enrolled in a Medicare Advantage (MA) plan, up from only 13% of beneficiaries in 2004. But do these plans actually put beneficiaries at a disadvantage if they get sick and need higher levels of care? The evidence suggests, yes.

Kiplinger’s recent article, Ill Health Often Leads to Plan Switch looks at a number of recent studies, including a 2017 review from the U.S. Government Accountability Office, pointing to this disadvantage, and found that sicker beneficiaries are far more likely to disenroll from their MA plan and return to Original Medicare than healthy beneficiaries. Another study by Brown University researchers found that Medicare Advantage enrollees are more likely to enter lower-quality nursing homes compared with people on Original Medicare.

People who are healthy tend to enjoy their MA plan and cheaper premiums than if they were in Original Medicare paying for their Medicare Part B monthly premium, a Part D prescription drug plan and a Medicare supplement plan (Medigap). Yet if/when illness strikes, people often realize they can’t see the doctor(s) they want or receive care in the facilities they choose. They are limited to the plan’s network, and the plan’s discretion on whether care is, or continues to be, necessary. This drives sicker patients to disenroll from their MA plan and use their Original Medicare.

In addition to MA plans’ cheaper premiums attracting beneficiaries, the Centers for Medicare and Medicaid Services (CMS) is also steering beneficiaries to enroll. One of CMS’ top objectives, as stated in a communication memo during Medicare’s annual open enrollment last fall, was to have a “renewed emphasis on MA plans.” Also, in CMS’ recent training materials for organizations helping seniors navigate coverage options, they emphasize MA plans over Original Medicare. When discussing beneficiary options during open enrollment, they only speak of the options to enroll into or switch Medicare Advantage plans. No where do they discuss the option of disenrolling from their MA plan and returning to Original Medicare.

One of our goals/vision statements at California Health Advocates is that “California will have fully informed and empowered consumers.” This is more challenging when some of the communication from the government entity responsible for all the “official” Medicare publications and training is misleading.

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.