Richard Helppie's Common Bridge
The problems we have in the country are solvable, but not solvable the way we’re approaching them today, because of partisan politics. Richard Helppie, a successful entrepreneur and philanthropist seeks to find a place in the middle where common sense discussions can bridge the current great divide.
Richard Helppie's Common Bridge
Episode 281- Medicare Disadvantage: Nate Kaufman and Rich Helppie Pt. 2
Are you getting what you pay for with your Medicare plan? This eye-opening conversation between healthcare insiders Nathan Kaufman and Rich Helppie pulls back the curtain on what they provocatively call "Medicare Disadvantage" plans.
When something sounds too good to be true, it usually is. Medicare Advantage plans tempt seniors with zero premiums, dental coverage, vision benefits, and even gym memberships. But these apparent perks mask a troubling reality: significantly restricted healthcare options when serious illness strikes. Our experts explain how insurance companies profit from delaying and denying care while creating increasingly narrow provider networks that limit access to specialists and top medical centers.
The most alarming revelation? The trap many seniors find themselves in when they discover these limitations. Once enrolled in Medicare Advantage, leaving becomes nearly impossible if you develop a serious condition, as new supplemental plans can exclude pre-existing conditions. Meanwhile, those with Traditional Medicare maintain freedom to choose providers nationwide, including prestigious research hospitals like Mayo Clinic or MD Anderson, without administrative barriers or insurance company gatekeepers.
For anyone approaching Medicare eligibility or reconsidering their current coverage, this episode provides crucial guidance. Our experts recommend a clear path: Medicare Parts A, B, and D, plus a comprehensive Medigap policy. While this combination involves upfront premiums, it offers something priceless: control over your healthcare decisions precisely when you need it most.
Subscribe to Healthcare Bridge on your favorite podcast platforms or find us at the Common Bridge on Substack to continue exploring the vital connections shaping our healthcare landscape. Your health decisions matter—make them with complete information.
Engage the conversation on Substack at The Common Bridge!
Welcome to this episode of the Healthcare Bridge, where we explore the vital connections shaping our healthcare landscape. Hosted by Nathan Kaufman, managing Director of Kaufman Strategic Advisors, the Healthcare Bridge is dedicated to improving healthcare delivery by strengthening the strategic and financial performance of healthcare providers. As part of the Common Bridge family, our focus is on fostering insightful, nonpartisan conversations that drive meaningful change in the healthcare industry. We invite you to join us as we build bridges toward a healthier future. The show is available on Substack, youtube and your favorite podcast platforms. Search for the Common Bridge and stay connected.
Speaker 2:This is Nate Kaufman with the Healthcare Bridge, welcoming Rich Helpe, the founder of Common Bridge. We're here today to talk about Medicare. It's known as Medicare Advantage Rich, you have another name for this thing.
Speaker 3:Yeah, I call it Medicare Disadvantage because if you pick unwisely, medicare Disadvantage could kill you or it might trap you inside and you never can get out. Now, nate, you and I have talked about this a lot. Traditional Medicare Part A it's free, it's automatic. Part B that's for your outpatient services, physicians. That's paid for on a sliding scale. It's an 80-20, usually pays 80% of covered charges. With that you need a Medigap plan. That's a private insurance. And then, of course, medicare Part D, which I'm a big advocate of. Medicare Part D. I think it's a well-designed plan. Medicare Advantage plans here's the pitch. You get little or no premium. You get added benefits like vision, dental, hearing and maybe transportation, a gym membership and over-the-counter drugs. So doesn't it seem a little odd that you could get so much more health care for so much less money? Does that sound possible? Like you know what they say if a deal sounds too good to be true, probably is.
Speaker 2:Well, actually there's another saying if you think health care is expensive, wait till it's free. I mean, the bottom line is that if you look at Medicare Advantage is that if you look at Medicare Advantage, the stocks UnitedHealthcare have all declined materially, and the reason they've declined is that sooner or later, people get sick. And the issue with Medicare Advantage is there's a number of ways you I'll call them loopholes, not cheats that you can find that will end up resulting in you getting paid more. One of them is representing how sick a patient is. That actually increases the amount of money you get from the government. So the insurance companies take lots of their money and invest in trying to make their patients look as sick as possible to the government so they get more money. Well, those days are limited because the government, after decades, has figured that out. Well, you take that loophole away and a few others, and now you have a bunch of sick people that you have to pay money to.
Speaker 3:So that's one way, that there's a way to manipulate the system. So we both have learned about people that said hey, what is this? I've got congestive heart failure. I never knew I had that, because some enterprising clerk put that diagnosis into the record. So again, just the distinction is Medicare advantage, medicare disadvantage is that the insurer gets paid a per member per month fee, and by our government, by the tax dollars, and that fee is set based on how ill that person is. But guess what else that you buy when you buy that medicare premium? You buy a gatekeeper, don't you?
Speaker 2:well, you, most of the time you buy a gatekeeper, but more and more the gatekeeper is the insurance company, and so the gatekeeper concept was you had to go to a primary care physician, get a referral in order to see a specialist. That was kind of a good idea because the gatekeepers were doctors. Now what happens is when you need to go to a specialist or get a procedure, that information is transmitted back to Minnesota or back to Indiana and some doctors AI system determines whether it's necessary or not, and then a physician spends like a few seconds reviewing that to see if he or she confirms and as a result, there's huge delays and denials in the system, and for every delay and denial of care, the insurance company actually makes more money because of the conflict of interest associated with I got my premium. If I don't have to provide for care, my shareholders make more money.
Speaker 3:Now contrast that with traditional Medicare. So let's just take this example, a generic example a Medicare patient on traditional Medicare is referred to a specialist at a research hospital you know, memorial Sloan, kettering, mayo Clinic, md Anderson, of course the University of Michigan and they have their traditional Medicare and the physician at that research hospital is willing to see them. What's the difference in the process versus somebody, that's say, coming from Southern Ohio with a Medicare Advantage plan trying to go to one of those specialty research hospitals?
Speaker 2:Well, what happens is you have to be, you go to what's known as an in-network provider. Let's talk about another loophole. You have to have an adequate network for your population and the problem basically, is that who's measuring adequacy? So they've done some studies where they see that insurance companies are creating ghost networks, that is, they list a number of providers that actually aren't available to provide care. That's first and foremost. The second thing is you can't go where you want If you have cancer. You can't just say, hey, I live in Oklahoma, I want to go to Johns Hopkins, which you can under traditional Medicare. You essentially have to go in network, which means choosing somebody locally.
Speaker 2:And what's happening? Because of the delays and denials and the underpayments coming from the Medicare Advantage plans, many, many of the really good doctors and hospitals are dropping out of Medicare Advantage. Of the really good doctors and hospitals are dropping out of Medicare Advantage. And keep in mind, once you're in Medicare Advantage for a year, if you leave, your supplemental plan is no longer based on the community, it's based on your own personal health care. So if you leave because, say, you've got I don't know pancreatic cancer, your supplemental plan is going to say we're covering this person, except for pancreatic cancer. So for that reason, because I'm on Medicare, I see no good reason at all to let a for-profit insurance company set my network, tell me where to go, tell me which care I can have, et cetera, and so I just encourage everybody to stay out of it.
Speaker 3:The term of art that those of us on the inside know. It's called a narrow network, and the way that the insurance provider can dictate price is to tell the health systems that you want to go that they're not in network. So they're saying we won't send you our patients if you don't meet our price point. And so therefore, while you might want to go to Johns Hopkins, you've got to go to ABC Hospital, which may have substandard care compared to Johns Hopkins probably would with specialties like that versus if you have traditional Medicare and you have a diagnosis and a provider is willing to see you. That's all there is to it. The doctor makes the decision, the patient makes the decision. Now, of course, medicare has its rules, but you've already got the diagnosis in hand and most doctors, most hospitals accept Medicare, and once you accept one, you've got to accept all Medicare patients, so you're going to have much more choice with traditional Medicare.
Speaker 2:Yeah, I mean I can't emphasize enough how important it is to select your providers properly. I just had a colleague recently who had this strange illness just pop up. The ambulance took her to the local community hospital and they basically said we better ship her to University of California San Francisco right away or she's not going to make it. And the fact is that that is not an inexpensive hospital to be transferred to. But had they not done that, she probably wouldn't have survived. So again, we want people who are informed to make decisions about our healthcare, not AI and remote physicians that really have no experience with a particular patient physicians that really have no experience with a particular patient.
Speaker 3:So I think we've landed in the same place. Nate Medicare Advantage, while it looks like it's such a good deal, you're buying a narrower network. You're buying a gatekeeper that can deny you care and you're dealing with someone whose incentive is to delay your care. Now, that's not to say that there aren't good plans out there. Some people are very satisfied with them. But guess what? Next year your network can change.
Speaker 3:So you know, if you like your doctor, maybe you'll keep them, maybe you won't. Indeed, that happened here in Michigan with us. We got a notification that they were having difficulty getting the Humana Medicare Advantage patients eligible because they were having negotiation issues with Humana. We're not in that plan, but our doctor said if you're in that plan you need to be alert. And again, that is not the Humana prescription drug plan, which works really well, but the Medicare Advantage plan part of it. So again, if you're put off by the premiums that you might have to pay under traditional Medicare, I remember you're going to get what you pay for, which is a very broad network and your ability to control your own destiny, much better than these Medicare Disadvantage plans.
Speaker 2:I absolutely agree, and you essentially get what you pay for, and, at the end of the day, when you're sick, you want those options that you don't have if you're locked into a Medicare Advantage plan and again, medicare Advantage is a great idea that's gone bad. And so, while there are people out there that are reasonably happy with their plan, the concern is, if you get sick, you need options, and you can't have options with Medicare Advantage. Anything else, rich, that you want to mention.
Speaker 3:Those people that are listening that are coming up to Medicare age. Four parts Medicare A you get that automatically. Medicare Part B definitely sign up for that. You'll need a Medigap plan to cover what A and B don't cover and that, depending on what market you're in, you're going to it'll be a Blue Cross or a United or you know whomever and then Medicare Part D and Medicare Part D very important to sign up for that when you become eligible, because even if you're not taking any prescription drugs, try to opt out. There's a big catch-up premium if you try to come back in later. So Medicare Part D is a very well designed plan. In a perfect world I'd make everybody eligible for Medicare Part D, but that's probably a subject for another day.
Speaker 2:There's a lot of nuances in healthcare and that's why it's important to ask an insider. And that's what we are, and this is Nate Kaufman with Rich Helpy with the Healthcare Bridge, signing off. Thank you for joining with Rich Helpy with the Healthcare.
Speaker 1:Bridge signing off. Thank you for joining us on this episode of the Healthcare Bridge. We hope you gained valuable insights into how strategic and financial analysis can transform healthcare delivery. Remember, building stronger connections in our healthcare system is a collective effort and we're honored to be part of that journey with you. Be sure to subscribe and stay tuned for more conversations that aim to bridge gaps and create a healthier future for all. You can find all your Healthcare Bridge episodes at the Common Bridge on Substack, youtube and your favorite podcast platform.