March 14, 2025 - Medicare Advantage

[00:00:00] Speaker A: ProactiveMD. From ProactiveMD and Makorx, this is Healthcare Explained. I'm Jeremy Vanderkinijf. [00:00:13] Speaker B: And I'm Vinay Patel. [00:00:14] Speaker A: Vinay, before we kick it off, you've been traveling this week, as I understand New Orleans, is that right? [00:00:19] Speaker B: That's right. That's correct. [00:00:21] Speaker A: How was your trip? [00:00:22] Speaker B: It was amazing. My daughter and I went, her friend is actually lived in New Orleans for about eight years and so she had some friends there and they had told us a couple months ago about you have to come to, to Mardi Gras. And my wife and I are both aghast, thinking, the last thing I want to do is expose my daughter to Mardi Gras. And they're like, no, no, no, no, you don't understand. There is a whole community behind Mardi Gras that you don't get to see because you just see all the crazy stuff that happens in downtown New Orleans. And I have to say, we were pleasantly surprised. There is a really warm, welcoming community in New Orleans. And the amount of just craziness that goes on in a good way in terms of having these parades, really putting the kids first and having all these things, the one thing that it does do for you is that when you experience a Mardi Gras parade, it ruins all other parades. And this is, this is something Layla's friends, my daughter's friend's dad told me was that, that whenever my kids go to a Christmas parade or some other parade, they're like, where's all this stuff? And they're very disappointed. And so there's no other parade like the Mardi Gras parade in New Orleans. And it was really cool. She had a ton of fun and we both did. And it was, it was a great experience. [00:01:44] Speaker A: Very exciting. You know, I, I have been to New Orleans many times in my public health days. Worked with a group that was kind of headquartered Louisiana Public Health Institute in New Orleans. I've never been during Mardi Gras, but I'll tell you the thing that for people who have never been to New Orleans that I explain it as, it'll be a Thursday in September and you will look out the door and there will be a parade of people with a sousaphone and like, you know, a one man band just having their own parade on the side of the street. No other city in America, I think, is like that. So I'm glad it was altogether a wholesome experience for, for you and, and your daughter and, and I'm glad you're back. We're recording today towards the end of February. We've got an exciting show. Vinay, what do we have on tap today? [00:02:32] Speaker B: We do have an exciting show, Jeremy. We're going to be talking about the Department of Justice investigating United Health Groups and their Medicare Advantage billing that was published in the Wall Street Journal. We're going to be talking about an update on the Morbidity and Mortality Weekly report given us information on a few weeks ago after there was a lapse in that publication. Also an update on avian flu and measles in Texas. And then we'll talk about our explainer, which is what is Medicare Advantage? [00:03:07] Speaker A: All right, well, let's get into it before we talk about what is Medicare Advantage, Vinay, what's going on with United and the doj, allegedly so? [00:03:17] Speaker B: Well, one trend that we've noticed or that I've seen over the last 10 or so years is there's two ways to access Medicare. One is your red, white and blue card. That's what's called straight Medicare. You sign up for that and you get, you go to the doctor's office and you pay a percentage or a cost to see your doctor and you pay a cost to when you go to the hospital for a fixed amount of days. The other way you can access Medicare is through Medicare Advantage. And we'll get into the details of this when we explain Medicare Advantage. But that's just a private insurance company offering seniors access to Medicare with typically extra benefits. And the way that they get paid is the government pays them based on the severity of how sick of a population they take care of. And part of the way that they do that is by, for, for a doctor's office is basically how you code, quote, unquote, every encounter, every visit you have with, with a patient of yours. So in this case, sickness scores for United Health Groups, Medicare Advantage patients increased by 55% in the first year of enrollment compared to average of 30%. The Department of Justice is interviewing providers to understand how the UnitedHealth Group software and provider communications are promoting certain diagnoses. And already under separate DOJ antitrust investigation around Optum and attempted acquisition of Amedisys. And then of course, UnitedHealth Group spokespeople are denying Wall Street Journal's latest report. Yeah, so tell us some more about this, Jeremy. [00:04:55] Speaker A: Yeah, and I know we'll hop into the explainer. So United's obviously been in the news a lot over the last few months. You know, there was a year ago, we're at a year anniversary of the Change Healthcare breach. Change Healthcare was Attacked by a Russian linked ransomware group which breached personal health information for millions of Americans. Because, you know, change sits at the core of so many interactions in digital health. But that was owned by UnitedHealth Group. And then there's the, the, you know, the, the tragic murder of their CEO Brian Thompson, back in November. Yeah, October, November timeframe. And, and now they're, you know, already in under investigation for antitrust. So UnitedHealth Group, you know, is a very large insurance company who owns UnitedHealthcare, which is the medical insurer. They also own Optum, which is the pharmacy benefits manager. So you know, they're looking to purchase a Medicis, which has historically been a home health provider, health care services provider. And so there's a lot of scrutiny or has been a lot of scrutiny, you know, even under the previous administration around antitrust for uhg, because they are huge. They are controlling so many different integrated aspects of the healthcare system. I think what's really interesting about this one on Medicare Advantage though is it's the idea that the insurance company is stepping in to potentially allegedly. Right. And according to the Wall Street Journal's reporting that you have the insurance company, UnitedHealth Group reaching out to providers and training them to do what, what we would call upcoding or you know, intentionally and potentially illegally or fraudulently adding diagnoses or adding procedures that were done. And the reason why this is so important in Medicare Advantage that we'll talk about is that it makes the patient population riskier, so the sicker they appear based on the claims information that comes in, that information is reported to the federal Government and then UnitedHealth Group receives the subsidy from the federal government from Centers for Medicare and Medicaid Services to be able to fund this health plan. And so I'm just going to say it, Vinay. It seems like every week when we're having a conversation, we're doing updates in the news, it is either someone is suing an insurance company company, an insurance company is suing someone, a pharmacy is being sued or suing someone. There is just in this case hasn't hit the courts, but obviously there's, you know, Wall Street Journal is saying that there is this investigation going on. Insurance is just a, it's not that it's a dirty business. I think it is just a business that is under so much scrutiny and there are, because of, like we've talked about in previous episodes, there is such a lack of transparency. There is so much opacity that is just baked into the insurance model that it, it Creates an environment where corrupt actions could be either harder to detect or, or more profitable. Right. For bad actors. So that doesn't necessarily mean that the company itself is evil. It doesn't necessarily mean that, you know, everybody at the top is directing this. It's just that you're creating these environments where you don't have that counterbalance of, of price transparency or really understanding what's going on. With a federal health program like cms, you're, you know, there's Freedom of Information act requests, there's ways of receiving information about how well that program is performing or not that we just don't see among private insurance. And so it just feels like, it feels like it should be a recurring segment who's getting sued this week, who's getting investigated this week in the larger health care space. But Vinay, I'm, I'm curious to know what your thoughts are on this, if you've had any experience with this type of billing creativity or alleged billing creativity in your past experience. [00:08:46] Speaker B: Yeah, honestly, we, this, this is a problem as old as time because of the way the medical, the healthcare infrastructure is. The payment systems built around fee for service. And with fee for service, the more that you do, the more you get paid. And sort of the logic makes sense. If someone's really sick and you have to do a lot for them, you should get paid more for than someone who's young and healthy and you need to talk to them maybe once a year to do a checkup on them. And so we've, we've, I've experienced this a bit in the past. Not again. Nothing like this exists in pharmacy in terms of upcoding. They, they have their own separate issues in terms of extracting revenues. But this now goes into the debate of okay, well what's the alternatives? What else can we do? How else can we change the healthcare payment structure from, away from fee for service? And there's been conversations. In fact, I read a fascinating article comparing, you know, there was a, an innovation center, it's called Centers for Medicare and Medicaid Innovation, I think, or cmmi, that was set up after the, the Affordable Care act went into place to try to find alternative payment models for Medicare. And one of those was value based care and taking Risk. And the funny thing is that there was a summary of sort of all the innovation and what kind of quote unquote savings it generated Medicare. And in fact every CMM or innovation program that was put in place actually cost Medicare money was surprising in terms of, you know, value based care. Capitated payments except for four. The one outlier was medic, the Maryland all payer system. And it really started with the problem first and said okay, well where's do we want to pay hospitals to take care of sick people and the system doesn't support that or do we want to pay hospitals to really be incentivized to keep people out of their doors? And that's really what the medic, Maryland, excuse me, all payer system does and establishes just a, a flat fee doesn't matter what insurance or what care, quote unquote, Medicare, Medicaid or otherwise. A patient has a health system can be guaranteed revenue for every patient that they care for. And that really created a tremendous amount of savings for Medicare. And one of the one that was highlighted in this sort of summary. And so there needs to be some more discussion around alternative payment models and trying to find the right one. I don't think that there is a perfect one fits all that's not fee for service. We see all the problems with fee for service because we've been using it for so long, but there's potential pitfalls and unintended consequences of other payment models as well we may not be seeing. And so we really got to figure this thing out and try some more experiments and have a good debate about where do we need to go from here. [00:11:40] Speaker A: Absolutely. And it's very interesting about the Maryland all payer model. And again, you know me, I'm going to beat the drum of value based care, actually align incentives to outcomes rather than to activities. But I think what's, what's unique about this particular case as we kind of wrap up this particular topic is typically when we think about upcoding and you know, fraudulent billing practices, usually it's, it's insurers that are, you take a, let me take a step back. You take a commercially insured population, the risk is borne by the insurance company. Right. Everybody pays their premium. So the insurance company does not want to see a whole lot of additional coding and a whole lot of additional reimbursement. And that's where we get into these conversations and national conversations reignited on the heels of, of, you know, the United Health Care CEOs shooting in New York was where we're getting into claim denials. And can we think of a reason to get around this? What I think is really intriguing about this one though is that here it is the insurance company allegedly. How many times am I going to say that? But the insurance company allegedly reportedly taking on the role of encouraging the physic to upcode, because unlike a commercially insured population, United would be receiving greater reimbursement from, you know, the more that these doctors are coding as far as diagnoses. And that's where we'll talk about the difference between the diagnostic coding and then the procedural coding here in just a minute. But let's talk about what's killing us this week. Our one for now recurring segment. But before we get into that, Vinay, I need to do a mea culpa on our last episode because there were a couple things that I said, one of which was true at the time, both of which were true at the time, but never take me to Vegas because I am terrible at predictions. So the first was, you know, we reported in our last episode around the cdc, as a result of executive orders had kind of stopped all public communication. So the Morbidity and Mortality Weekly Report, which has been around since forever, we weren't being communicated with from the cdc as national news outlets were picking up on avian flu, all of a sudden the cdc, which has, you know, historically been the nation's and one of the world's, you know, leading sources of, of information, statistical information, et cetera, trends, population health trends, had gone silent. Now I am happy to report that they have now resumed releasing of the mmwrs. We saw early executive orders put in place pending new leadership being installed at these different agencies, things like that. But I am happy to see that the MMWR is, is back up because it has always historically been viewed as a very important piece of public health surveillance. And it is publicly accessible, which can help public health nerds like myself, employers, anyone who's trying to understand disease trends and, you know, really what's killing us this week, I will use this word, reputable source, you know, scientific source. So that was, that was. Yeah, it is great news. And so I'm, I'm happy to see that, that it's, it's been resumed. The second I'm less happy about. In our last episode, we were talking about avian flu and the first recorded bird flu death in the U.S. occurring in Louisiana on, you know, the question was, how is it, how is it spread? And again, there's been a, there's been a gap of about three weeks between recording that episode and recording this episode. And so when we recorded that episode, you know, there was limited information to suggest that avian flu at this point had mutated to become airborne. The primary sources of transmission that we were being warned about was human to animal transmission, which could be human to Poultry, but also just, um, you know, in a, you know, a farm or a ranch type of scenario, you could have it make the jump from, let's say, chickens to cows and then cows to humans. So it was that zoonotic mode of transmission that we were being warned about. So naturally, naturally that's changed because such is the way of the world of disease. And also I should just keep my mouth shut and learn to protect the global population by just shutting up sometimes. But there was a study that just came out of the Czech Republic where they were able to actually demonstrate strong evidence that bird flu had, had managed to migrate from, you know, I think dozens of miles away from one farm to another, where they looked through. Both were highly biosecure. There was no cross pollination, if you will, of humans entering one facility to the other or the livestock being shared. But they looked at weather patterns and everything else, and they've drawn the conclusion that the avian flu move from one farm to the other, one commercial farm to the other. It was airborne. That wind played a pervasive factor. And so again, this is the first report, but it's not the, it's not, it's the first report that draws that strong of a connection. There have been other, other smaller studies and whatnot that have suggested that it could be transmitted through respiratory droplets, but, you know, it was less of a concern. It didn't seem like that was the primary means of transmission. I don't know. You know, I don't pretend to be an epidemiologist, but I think the epidemiologists are certainly perking up their ears as they heard this report coming out of the Czech Republic of. All right, is this something where we need to be? Is this a case of mutation, that it was previously not primarily airborne but is mutated? Or is this a case of we were perhaps incorrect or had insufficient evidence to be able to previously, but these existing strains are, are airborne. So that's not great news. No, you know, it's. I don't think anybody's looking forward to another global pandemic, but I think the advice we gave last time of wash your hands, especially if you're working with animals and things like that, that doesn't change. You know, we still. No, I'm not, I'm not even going to say it. You know what? I'm just going to keep my mouth shut. I'm going to keep my mouth shut. Wash your hands, be safe, be careful. [00:17:57] Speaker B: That's right. If you feel like you need extra protection, wear a mask. [00:18:02] Speaker A: Exactly right. Exactly right. You know, latex gloves, never. Well, I shouldn't say that. If you have a latex allergy, latex gloves absolutely did hurt you. Nitrile gloves. Right. If you're one of those people who does not have an allergy to ppe. To your point, Vinay, absolutely. If you're, if you're doing a school field trip to the local dairy farm, you know, up in Wisconsin, Midwest, send your kid if you want. Right. To wear gloves during that, it's not going to hurt them. It's not going to hurt the animals. So speaking of children and unfortunate news, there's a measles outbreak in Texas that's going on, that's being reported on and this is the largest, the largest outbreak of measles in Texas, I'd like to say since the late 90s or early 2000s, but it's been, I think, 50 plus confirmed cases within Texas. There's also been reports at the New Mexico border that there could have been additional folks that were infected as a result of the outbreak. So again, epidemiologists look at an outbreak, they try to trace back down to, we call it in popular culture, patient zero, but really understanding what is the epicenter of that disease. And then when they see cases that were clustered either because of geography, because you know, everybody into the same church or part of the same community, or kids in the same school, or if they're able to see the genetic markers or equivalent across strain that was identified over here and over here, they do look to try to combine it to understand into one outbreak. Right. One event. And so I will say this again. We talked in our last episode. There was a time, Vinay, I'm, I'm going to be transparent here. There was a time when vaccination was not nearly as politicized as it is today. And I think what we've seen is just a result of backlash and communications, that mixed messaging, everything that happened during COVID I think what we've seen is that vaccination, which has always been kind of on the periphery. There have been smaller groups of people, again, unassociated with a political ideology typically. In fact, the classic example was that a lot of anti vaccine sentiment started among what we might consider members of the left wing that were viewing it as, you know, kind of unnatural. It was the work of Andrew Wakefield, who's the physician in the UK who had, I will use the word disgrace, lost his license as a result of strong evidence that the, the link between childhood vaccines and autism, the data had been faked. Had been fabricated. There was a clear conflict of interest. He was being paid by attorneys who were seeking to represent parents to find a link. And the journals that published that research, it's been retracted. But measles vaccination is one of the greatest public health successes of the 20th century. And it, it does upset me. And I'm sorry if this, you know, irritates some of our listeners, but to hear newfound backlash against vaccination, because the fact of the matter is that, you know, out of every 10 kids who gets measles, at least one is going to end up in the hospital. I think I saw that out of every thousand, four kids will die. And this is an entirely 100% preventable disease. It's not. Well, it might be a little bit effective. Can argue about the efficacy of flu shots and, you know, on a good year, they're 25% effective. The measles, the. Mmm, excuse me, MMR is 100% effective at preventing childhood measles. And so as a father, you know, especially knowing that there are kids out there who cannot have the vaccine because of allergies to some of the key ingredients, things like that, herd immunity is incredibly important. And so when we start seeing outbreaks of preventable childhood illness that will potentially kill children, to me, it's. It's heartbreaking and I. I feel like it shouldn't need to happen, but I'll get off my soapbox. And Vinay, I'm curious, as a pharmacist and somebody who is able to actually provide these vaccines, Right. And what's your take on something like this measles outbreak? [00:22:12] Speaker B: I concur with you, Jeremy. Again, and we've had this discussion in our family as well, internally extended family members, on what you think about vaccines and does it really have harm? There's a very unique setup in vaccines that doesn't exist in other parts of the pharmaceutical industry. There's actually a fund that every single manufacturer of vaccines puts into that the federal government has access to. And so if you have any claim that there is a link to a vaccine causing any issues at all, you can, you can actually apply to get. Make your case in front of a judge, and if there is a link, get reimbursed for any kind of adverse event, serious adverse events that you would get from a vaccine. And it's sort of. It's unique in the pharmaceutical world and the vaccines have created that, and we've done all kinds of research as a, as a pharmacist. I remember going out as a pharmacy student Remember going out and doing clinics where we would give flu shots before it was widespread that pharmacists could give flu shots, and educating the public on why it was important to get vaccines. Now there's more accessibility than ever, than ever before. Before, you used to just have to get at your doctor's office. Now you can essentially walk into a pharmacy and get many, many vaccines, many routine vaccines, in fact. So the accessibility, convenience and the, you know, safety. Now, after another two decades, three decades of data that have come out showing why vaccines are important, how they help, it's one of the few ways we have at prevention than treatment, rather than waiting till something bad happens and treating it, it's it like something that society has created that, that helps us live longer and helps us to be healthier and be more productive than having a society in the 1800s and early 1900s where you were lucky to live past 40, 50. I think it's important and I think that, that everyone should educate themselves, have this discussion, discussion and debate. But I agree with you that over the last five years, through the resurgence of vaccine information coming out, people have started to second guess other vaccines now because of what they felt, heard, experienced in their own, in their own right. We should try to, to right this ship and try to make sure everyone has all the right information and is well informed going into it. I think we had a lot more resources dedicated to vaccine information education than we do today. But, but nonetheless, we have an opportunity to help, influence and change that. We should exactly get that. [00:24:53] Speaker A: And I'll. You know, again, as, as we've always said in our pilot episode, you and I are not out there to give clinical advice. You actually have a license that would allow you to give some clinical advice. But the advice that I can give is if you're concerned about vaccines for yourself or your, your family or your child, talk to your doctor about it. Talk to your doctor, a person with whom you have a trusted relationship to take care of you and your family, who you know has your best interests and heart, and talk to them about your concerns and let them talk to you. You don't need to listen to me. You don't need to listen to Vinay. But that also means you don't need to listen to other podcasters who might be saying the opposite. Talk to your doctor and figure out what's right for you and your family. But my heart goes out to the families of the folks in Texas and, and beyond. If this continues to spread, I hope that every one of those kids, because it's it's, you know, measles is a disease that is much more serious if it impacts children than, you know, than an adult, except maybe older adults. So I hope everybody feels better soon and that they're able to get this contained and under control. [00:26:00] Speaker B: Agreed? Agreed. For those kids, absolutely. Okay, onto our explainer. Jeremy, let's talk about what is Medicare Advantage. Kick us off here. [00:26:11] Speaker A: All right. So you know, we hear the word Medicare probably, if you ever listen to the news, you probably hear it three times in every sentence. It is one of the vital public programs that's been established since the, I believe the Kennedy administration first put it in place with this idea of, okay, as healthcare costs are starting to increase, adults are living longer and making sure that there is a safety net program to be able to not just make sure that these patients, these folks are able to have access to care, but also remember who's getting reimbursed by Medicare is it's the actual providers of the healthcare. So make sure that you're not having hospitals that are going bankrupt because you have a bunch of highly complex cases with older, unhealthier adults. And there's no means, oh well, they stopped working. They don't have health insurance. So they're just going to fall through the cracks or the hospital is going to have to accept all of this care as charity care. And so Medicare Advantage is distinct from traditional Medicare. And let's define traditional Medicare. You mentioned the red, white and blue card earlier. And when we tend to think about Medicare, that's what I think a lot of us think of is it's the you turn 65 and you're enrolling with the federal Medicare program that's administered by Centers for Medicare and Medicaid Services and in the D.C. area. So Medicare, traditional Medicare is four parts. The first is kind of referred to as the hospital insurance. If you have an inpatient stay for some kind of important, you know, you had a heart attack and end up in the hospital or you know, you're in a rehab, short term rehab facility for 30, 60 days, you know, following an accident. That's where Medicare Part A covers. Then you've got Medicare Part B, which is your outpatient care, your doctor's visits, durable medical equipment, you know, your mobility. You've kind of lost your mobility. You need a rollator, a walker, a wheelchair. It's Medicare Part Part B. You've got Medicare Part D, which is your prescription drug benefits that Vinay, I'm not even going to pretend to talk about. You're the expert There Medicare Advantage is sometimes referred to as Medicare Part C. And so it was established as a new program in 1997 because nothing in the federal government or federal code can ever be easy to understand. Think of Medicare Part C as including A and B, parts of A and B and maybe some of D. So mention traditional Medicare for a second. Right. I'm an older Adult, I'm 67 years old. I go in for to see my doctor for sinus infection. I have my red, white and blue card. I present it to my doctor who accepts Medicare as Medicare credentialed. They submit a claim to cms and CMS then provides a reimbursement based on what the CMS rates are. Every doctor in America who accepts traditional Medicare is going to be paid the same amount, which is typically not as high of an amount as they would be reimbursed under a commercial health plan. Which is why you sometimes hear, and we'll do a whole other explainer on the idea of reference based pricing being a percentage of Medicare. It's kind of a national standard. And then everything's either higher or lower than that. Medicare Advantage is, as you mentioned, Vinay, it is delivered through private health insurance companies. So think about groups like Humana or your Blue Cross Blue Shield, you know, Anthem, slash, elevance, whatever they're called today. Cigna, right. They offer Medicare Advantage programs. And so the way that that works is that they leverage typically their existing network. So maybe their Blue Cross network that they have, providers will get reimbursed to participate in this and accept the Medicare Advantage plan that this payer is putting out there. Here in South Carolina we have the preferred Blue network through Blue Cross Blue Shield of South Carolina. So if you're a provider who's part of the preferred blue network, you'll get paid preferred blue pricing when you file your claim to one of these plans. But there are a lot of nuances in the way that Medicare Advantage can be delivered. The reason why you have a group like United that you know, courting reportedly is encouraging the doctors to over bill is that the way that the insurance company gets reimbursed from the federal government is kind of there. There are two factors. How sick is the population? What were the health outcomes of the population? [00:30:34] Speaker B: And there's their star ratings, which is basically feedback from the patients on how well customer service wise. [00:30:41] Speaker A: Exactly. And so those star ratings, and I think it's, I'd like to say it's an acronym for some reason because I always see a capitalized. But those are based on these measures that are called hedis measures, to your point, Vinay, coupled with the patient experience. So the goal of Medicare Advantage is to reduce the costs for the federal government, for taxpayers, Right? Because instead of cms, which has its own, you know, large bureaucratic organization to be able to run, they're not necessarily well equipped to be able to manage care on an individual level with every individual patient. But health insurers do have that. They've got care management, they've got utilization management, they have case managers who do patient outreach. They are paying attention to gaps in care. Medicare, traditional Medicare is not really going to yell at you for saying you haven't had your annual wellness visit go in there, right? They can't develop incentives for that, but a Medicare Advantage program can. So the idea behind it is that instead of everything being direct from CMS to the providers for reimbursement in a fee for service, very strict fee for service type of environment, what if we actually incentivized health plans and insurance carriers to lower the cost of care? By leveraging what they've got to be able to deliver targeted personalized care efficiently, we can take advantage of their networks and their provider networks, and they're going to be the ones who are doing all this contracting. And the way that we offset that cost savings to make sure that we're not rationing care is with star ratings. It's making sure that are you actually delivering outstanding care? Are you controlling A1C in diabetic populations or, you know, lowering the risk of heart disease? That's why we get into diagnoses. So the sicker population, CMS will want a Medicare Advantage population to care for a sicker population or a more population with more complex healthcare needs. And as a result of taking care of a sicker population, if you're able to reduce the overall cost of care, then these MA contracts between the payer and the government are shared savings programs. So say the average older adult is $10,000 a year on traditional Medicare. Well, if you can prove that you took care of that adult for $8,000, then let's split the savings, right? You get to keep an extra thousand dollars and cms, you know, gets to keep an extra thousand dollars. And everybody wins. Patient wins, insurer wins, taxpayers win. But in order to make it equitable, in that is, some populations, the average cost might be 20,000 because you've got a whole lot of folks with diabetes or a history of cancer, things like that. So they have this thing called the risk adjustment factor, the RAF score, and Every patient gets a RAF score, and it's calculated by cms, it's calculated by the insurers and reported to cms. CMS will also validate based on the information that they have, and it's all based on diagnoses. And, you know, the joke in the Medicare Advantage world is if you don't report that somebody had a limb amputated every year, then in the eyes of CMS and Medicare Advantage, that limb must have grown back. So doctors are trained to, or not doctors themselves, but their practices are trained when caring for Medicare Advantage patients. The providers are saying, listen, we'll give you additional kickers if you're taking care of a sicker population and controlling their costs. So they're passing some of that shared savings onto the providers as well through different arrangements. But, you know, we need to make sure that you tell us exactly how sick that patient is. And so it's not just a matter of saying, well, Vinay, you had diabetes, so I'm just going to code that. It gets very detailed into you have diabetes with this complication. This complication, this complication, because all of those are cumulative as part of that RAF score. And I think that circling back to what happened at the, the news story we were discussing at the start is when you have an insurer who's reportedly saying, upcode, maybe if they don't have complicated diabetes, go ahead and say it's complicated diabetes, or if they've got slightly elevated blood pressure, go ahead and call it hypertension. If that's the type of activity that's going on. What that does is that raises the risk of the population that gets reported back to cms, and so then the insurer would be paid more money. But again, the, the potentially fraudulent piece comes in is that if those patients did not actually have that acuity of diagnosis and you're coming in and saying that they, they were sick like that, or encouraging the providers to, you know, to just go ahead and UPCODE on that, then what you're going to see is a population that sick should have been $20,000 is what Medicare would calculate. You know, but, wow, you were able to take care of them for $10,000 per member. That's $10,000 savings, which should be great news. But if really you took care of that 10,000, you know, $10,000 patient, because they really shouldn't have been predicted to cost more than $10,000 because they weren't that sick, they didn't have as many conditions or as acute conditions, as you said, then that's where DOJ is going to take an interest and where they're seeing like 55% increase in this population. Before they enrolled in MA, this was their history. Now it appears they're 55% sicker versus the rest of this industry is showing 30% on average. They're going to say are you, are you up coding to try to get CMS to pay more money like we talked about. There's just a lot of opportunities, you know, to potentially have problems in any opaque healthcare system. But you know, one thing I'll say before turning, turning it over to you, Vinay, and getting your take is Medicare Advantage writ large has been, has shown success. The average MA patient, they've done studies cost $1,500 to $2,000 less in a year than a traditional Medicare patient. And again, it's not because care is being rationed. That's why you have those star ratings to make sure patient needs are being met, gaps in care are being closed, they're getting the medication they need. But you do have through that insurance company that's got aligned incentives for value based care, they're going to be taking a closer retention and then again developing their plan to work with providers to say, hey, if you're able to take care of this, stop referring this person out to every single specialist. As a primary care physician, you can get a kicker for managing their annual wellness visit or managing their diabetes. And if you can show the outcomes, why don't you get that money instead of the specialist? So it does open up a lot more creativity than traditional Medicare can do to drive those incentives. But on the, on the flip side, you know, you could have these cases where it, it can also introduce the potential for fraud. Vinay, what are your thoughts on Medicare Advantage or any experience that you've had? [00:37:25] Speaker B: Yeah, so I'll just say a couple of things from the patient's perspective. You talked, you explained how it affects providers and how the arrangement changes, potentially changes provider behavior or influences it. And from a patient perspective, you know, Medicare Advantage, typically there's one's not better than the other. Every patient has to make a decision for themselves. Typically Medicare Advantage plans have richer benefits and it's more fixed monthly outlays of costs instead of spikes in costs whenever you need access to care. But there are benefits to traditional Medicare and for some people traditional Medicare is better and gives you more access to providers potentially. But again, one resource that is set up for every senior citizen and anyone who's considering signing up for Medicare in the country is something called the state health insurance assistance programs. These are what the acronyms called ships. They're ships in every single state. They are Medicare counselors that know everything about Medicare, A to Z, soup to nuts that can help guide you to pick the best plan, whether it's traditional Medicare and a supplemental plan or whether it's Medicare Advantage and then also things that we didn't even touch on which is Medicare Part D, the whole prescription benefit and why it's important, important to sign up for that as soon as you turn 65, even if you don't take any medications. We'll cover that in a later episode. But please reach out to your ship counselor, Medicare counselor in your state, in your area. They'll know a lot about which plans cover if your doctor's in network or if it's not and why. And so they're a great resource. They're unbiased, they're paid by Medicare to be a resource for the communities. And so please utilize them. And please educate yourself about Medicare before you're even close to 65 so that you know what your options are and what you need to do, whether you're working or you're not. Reach out to these Medicare counselors that can help guide you through this process. It's extremely complex and I wish it was simpler. I think it should be simpler for the folks in our country that need it the most and who are sort of work their entire lives for this benefit. But here we are. So use the resources you have. [00:39:26] Speaker A: That's a great point. And one note for employers also. You know, one of the things we hear from employers is they have employees who are Medicare eligible but worried about moving on to Medicare because they're worried about the level of care that they'll get or the loss of benefits that they get through their, their employer sponsored insurance plan, you know, their commercial network and things like that. And so if you're an employer who you know does have an aging population or folks that are considering that again as an employer, you're not in a position to be able to force or even encourage somebody to go on Medicare. But you can know the resources that are out there like, like the ship in your state that you mentioned, Vinay. And also just letting people know that if they're happy with their doctor, right there are could be a Medicare plan if they're with, if their doctors with cigna, because that's the network that the, that the employer uses as part of their health insurance plan. They really like their doctor and they're worried that they're because that doctor doesn't accept traditional Medicare, there's a chance that that doctor may be able to remain in network through a Medicare Advantage plan offered by that insurance company. So educate yourself on that as an HR benefits professional, on what options are out there for your employees as they're entering the Medicare age and they're not ready to retire. But they are also wondering, if I don't retire, do I need to stay on the insurer, employer's health plan? Because it could be that they get richer benefits or lower deductibles through an MA plan. And then you, as the employer, of course, would no longer be covering the costs for that employee. So again, you can't force people onto Medicare. That would be, that would be against the law. But just making sure that you're educated in those plans and those options so that you can continue to support your employees and empower them to be able to go out and seek those resources to make the best decisions for themselves. That's right. [00:41:13] Speaker B: All right. [00:41:13] Speaker A: Well, Vinay, that's a, that's another, it's another episode in the can here. Any closing words of wisdom for us today? [00:41:21] Speaker B: I think with everything that we've heard today, I would want to make sure all our listeners are safe and healthy as we try to wrap out this winter season here over the next couple weeks so that no one that hasn't gotten sick this season doesn't get sick. And anyone that is sick, I hope a speedy recovery. But most importantly, stay safe and healthy. [00:41:40] Speaker A: Excellent. Thank you. And I'll just close with a thank you to our new producer, Emily Miller, who's joining our team to help keep Vinay and I online. So thank you, Emily. And with that. All right, well, I'm Jeremy vaynerkanife. [00:41:53] Speaker B: And I'm Vinay Patel. [00:41:54] Speaker A: This has been Healthcare Explained. And we'll see you next time. Proactive MD.