As I approach 65, I have Medicare in my future. The more I learn about it, the more I want to become an expat. Because Medicare is a horribly complex and half privatized, it’s a sign of Stockholm Syndrome that Medicare for All is the preferred branding for single payer when Medicare is no such thing. The reason that many look favorably upon Medicare is they have crap coverage now, say no insurance at all, a non-subsidized Obamacare plan (often meaning high premiums and high deductibles) or a not-very-good corporate plan (I know a big Pharma exec who reports that Obamacare will be an improvement on his company’s insurance). In other words, Medicare looking less bad is simply another proof of how crappy our health care, or more accurately, health insurance system is.

I am particularly dreading going on Medicare because I am in the microscopically small minority that has good and cheap private insurance. Some are lucky in love, some are lucky with investments, yours truly is lucky with insurance.

My insurance is a legacy policy. It’s a plan from the late 1980s. What was a mediocre plan then looks gold plated now, particularly it being an indemnity plan, which means I am not in an HMO or PPO. I can see any doctor in the world, no GP gatekeeping, and have submitted claims from the UK, Australia, and Thailand.

Rather than an overview, which I hope to eventually be able to produce, we’ll be tackling Medicare more deductively, working through issues and cases and hopefully to some bigger observations. So we’ll only set forth a few of the major features and then describe issues.

Medicare consists of a dizzying number of parts: Medicare A, which is hospital coverage. Proponents like to say it’s free if you’ve paid Medicare taxes for 40 quarters but it isn’t, since you are pretty much obligated to sign up for Medicare Part B (doctors outside hospitals) and Part D (drugs) because the penalties for joining Medicare B after you have started with Medicare A are draconian, and not having drug coverage if you take any is generally not a hot idea. So unless you are rich enough to be confident you can afford concierge services or pay out of pocket, you’ll wind up needing to pay for Part B and Part D coverage. Oh, and Medicare A is so skimpy that it’s preferable if you can afford it to buy a private Medigap policy too.

You can’t opt out of Medicare unless you give up your Social Security too. From E-Health Medicare:

In fact, if you don’t pay a premium for Part A, you cannot refuse or “opt out” of this coverage unless you also give up your Social Security or Railroad Retirement Board benefits. You’d also have to pay back your previous benefits to the government.

The only exception is you may be able to delay starting Medicare until after you are 65 if you are in an employer group health plan.

Let us look at some of the issues regarding Medicare.

Some doctors don’t take Medicare. Despite the efforts of some Medicare defender to deny it, it’s. None of my current physicians accept Medicare, while my current insurance covers them. I don’t look forward to having to find new doctors, particularly through the confines of an HMO or PPO, where I will be subject to its gatekeeping and won’t be able to go freely to specialists.

One of my friends plans to leave New York at 65, and the timing is driven by Medicare. None of her current doctors will take it. Rather than pay for them fully out of pocket, or have to get new NYC doctors (and she does not like the look of the choices), she will move to a biggish city in Flyover that had a good medical center and sign up for its HMO via Medicare Part B.

Having Medicare can seriously impede procuring medical services. Medicare prohibits medical providers who accept Medicare to take direct payment from patients for “covered services”. Note that most private plans allow patients to “self” or “cash” pay and then submit for reimbursement. ¹

Medicare has made it virtually impossible for me to get a nurse out to draw blood from my mother to get it tested. I spent a full three months at it with no success, contacting five different services, and only recently understood what the obstacle was.

For an annual MD exam, the bloodwork is arguably the most important single set of inputs. My mother’s doctor is in an enormous clinic that is difficult for her and me to navigate; it’s a lot to ask an aide to do what would in the end be close to half a mile of wheelchair pushing to get her to the test area and then to her doctor and then back to the car. Plus with Covid, why should she get risk getting infected by coming in when the clinic’s nurses are working remotely?

Her doctor did a telephone check up (telephone as telemedicine is acceptable under Medicare) and clearly still wanted her to come in for a blood test (he is very controlling). I finally got him to understand “no is no”. His nurse, who was not willing to put much effort into contacting private nursing services, rang up one that this clinic deals with, and which at one time sent out some physical therapists for my mother.

The nurse e-mailed to say that the nursing agency would not do a blood draw. I said we’d be willing to pay directly. I was told we could not do that.

I then tried calling two other agencies on my own. Both said they would not take a direct payment from or on behalf of a patient. The fourth said that there a way to code the visit as skilled nursing and include other tasks, like assessing my mother for physical therapy, and the blood draw could be bundled into that. She said she would talk to the doctor’s nurse about that. I thought we had this worked out, only to have this agency call back and say they didn’t take my mother’s Medicare Advantage plan, and they wouldn’t let her direct pay either.

The next route was that one of my mother’s home health care agencies had a nurse with a phlebotomy license. Note that home health care agencies often don’t provide medical services, only home aide services, and so the only insurance they might take is a long-term care policy, not Medicare. I thought we had worked out a price and that agency’s nurse was to call the doctor’s nurse to determine when she could pick up and drop off the vials. I heard nothing and called the agency. That nurse had quit and they didn’t have anyone else qualified.

I then tried calling a nurse I knew at one of the local hospitals to see if she had any friends who could do this on a private duty basis. No luck.

Then my mother went to the ER on a false alarm, so she got bloodwork plus poked and prodded and was given a clean bill of health.

When I grumbled to my doctor in New York about this mess, she said it was probably because it was considered Medicare fraud for a Medicare provider to take a direct payment from a Medicare patient rather than billing CMS.

Only then did it occur to me to go poking around, since no one I had dealt with even hinted that my difficulties came from Medicare, as opposed to weird policies of medical organizations run by MBA beancounters (like the one discussed last week, which insisted on taking a copy of my driver’s license, as opposed to just having a look to verify my identity, to take an image, even though I had already paid for the service via credit card and hence there was no insurance fraud risk). My assumption had been that these nursing agencies must have decided that self pay customers were too few in number to bother serving.

Nope. From Medicare.gov under Home health services. See the bold and italicized gotcha!:

How often is it covered?

Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) cover eligible home health services like these:

Part-time or “intermittent” skilled nursing care
Physical therapy
Occupational therapy
Speech-language pathology services
Medical social services
Part-time or intermittent home health aide services (personal hands-on care)
Injectible osteoporosis drugs for women…

Who’s eligible?

All people with Part A and/or Part B who meet all of these conditions are covered:

You must be under the care of a doctor, and you must be getting services under a plan of care created and reviewed regularly by a doctor.

You must need, and a doctor must certify that you need, one or more of these:

Intermittent skilled nursing care (other than drawing blood)
Physical therapy, speech-language pathology, or continued occupational therapy services.

These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively. To be eligible, either: 1) your condition must be expected to improve in a reasonable and generally predictable period of time, or 2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or 3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition. The home health agency caring for you is approved by Medicare (Medicare certified).
You must be homebound, and a doctor must certify that you’re homebound.

You have to be so “homebound” that you pretty much never leave (for church is OK though). So that works, but you can see that a blood draw is specifically disallowed! That seems bizarre since some meds, like the anti-stroke Coumadin, require very vigilant monitoring of blood levels, meaning monthly or more frequent blood tests.

But the fact that bloodwork is explicitly disallowed would make it a non-covered service, and thus legal for a Medicare provider to take a direct payment for it. But none of the nursing agencies I could find would even consider the question.

Honestly, if I weren’t needle-phobic, this would be enough to make me get a phlebotomy license, so as to never have to deal with this run-around.

Medicare is a huge tax on time. I am regularly working in a room with Old People TV on (ME TV and Ion, which has crime shows). The drug company ads were displaced in the last month with close to non-stop Medicare ads urging oldsters to call to “review” their benefits with “no obligation” to see if they might qualify for a cheaper/better plan. As readers pointed out:

Jeremy Grimm
December 7, 2020 at 9:08 am

And every year you have to re-examine all your policies to see how they’ve changed and compare with other similar policies as the relative prices for policies shift around.

antidlc
December 7, 2020 at 11:46 am

YES!

You have to check your part D plan each year to see what drugs are covered (or not covered).

When picking a plan, you have to decide what drugs you MIGHT need, whether they are on the formulary or not, and what tier they are in.

And the formulary can change at any time.

I cannot believe the time tax we have paid looking into all of this.

juno mas
December 7, 2020 at 1:13 pm

The tax on ones time goes beyond research. There is the interminable “phone time” waiting to connect with a Plan representative. I’ve spent HOURS waiting to talk to someone who knows anything substantive about the various plans. This year I simply let last years Plan roll over, so as not to have to endure this tax on my time!

But hey, neoliberalism says shopping is fun and a consumer benefit. So we all have to get with the program, right?

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¹ I do this mainly for privacy and not economic reasons, since my insurer’s right to have access to my records is much weaker when I pay for services than when the doctor or lab bills them. I have found that the “cash pay” rate is often better than my insurer’s best negotiated rate, and so my co-pay kicks off of that. Since I am not in a HMO or PPO with my insurer, it looks like a violation of the insurer’s contract with the doctor to force a network discount on them when they aren’t entitled to it. I’ve pointed this out to my doctors who’ve been subject to it (as in having me pay their cash price and then having my insurer they need to reimburse or credit me for some of it) but they spend so much time fighting with insurers already that they don’t seem to have the strength for it, and my taking it up with the state regulator years back got nowhere