Dr. Barry B. Perlman, a retired psychiatrist, is a past president of the New York State Psychiatric Association and past chair of the New York State Mental Health Services Council. He also served as a member of the state Hospital Review and Planning Council. “Rearview: A Psychiatrist Reflects on Practice and Advocacy in a Time of Healthcare System Change,” his memoir, was published in 2021. Perlman lives in New York.
Medicare’s annual open enrollment (OE) period is a crapshoot for its beneficiaries. During OE, I along with almost 66 million other enrollees are encouraged by Medicare to review our options for choosing a standalone Part D drug plan, a Medicare Advantage Plan or an Advantage plan that includes drug coverage. Visiting the Medicare.gov website enables enrollees to preview available plans from each category and select one suitable to their situation. The problem is that despite Medicare’s star system, which superficially reflects the quality of each plan, data essential to making a rational selection is absent.
Let’s begin with a personal example: 22.5 million Medicare enrollees, me included, opt for the Part D standalone drug plan. Each year during OE, I review available Part D drug plans by entering my ZIP code and current medications on the website. The star ratings offer little separation among the plans on offer. Because one medication I’ve taken for years is quite costly, the most significant discriminator is projected total annual cost. Each year a different plan has stood out as having the potential of saving me around $1,000. So, each year I make the switch.
What makes switching a throw of the dice is that my costly med always requires prior authorization (PA) from the new plan. The website offers no detailed information about plan denials or success of appeals. Should the plan deny the PA, my doctor would have to begin the time-consuming and uncertain process of appealing the company’s decision to the very entity which denied the original request. If our appeal is rejected, then my total cost for meds during that year would far exceed what my cost would have been had I opted to remain in my prior plan. For sure, I share this annual predicament with millions. It’s crazy!
It seems unreasonable to have to go through repeated PAs for a doctor prescribed, essential medication approved by prior plans! I think it ethically dubious to allow the clinical criteria established by plans to remain hidden from view and scrutiny as proprietary information. Recurrent demands for PAs only make sense if a goal is to maximize profits, as plans incur no penalty for denials reversed on appeal. It would make good common and clinical sense for a medication once prescribed and authorized by one plan to be exempt from subsequent PA requirements.
Neither is it easy for the 51 % of Medicare beneficiaries who opt for Advantage Plans to make informed decisions because the data most relevant to their receiving needed care on a timely basis isn’t available on the Medicare.gov website. Advantage plans are required to provide all services covered by original Medicare. Medicare’s current star system reflects member experience, the handling of complaints and appeals, how plans improve or don’t, the handling of chronic conditions and preventive care. While each element has value, what is most important to selecting a plan is the knowledge that when medical care is needed it will be readily available without the anxiety caused by having to surmount unnecessary hurdles.
Excessive use of PA and denials undercut the obligation of Advantage plans to provide equal access to services covered by original Medicare. To that end, data summarizing a plan’s PA requirements, denials, appeals, and reversals for important tests, procedures and treatments should be clearly displayed. Unfortunately, that information is currently unavailable.
In addition, data about plan provider network adequacy, necessary for access to care including mental health care, is absent. It is noteworthy that a mere 11% of denials are appealed even though 82 % of appealed denials are overturned. As always, the plans profit from inadequate networks, delays and denials, while suffering no penalty when denials are reversed. An anecdote illustrates how predatory marketing may redirect attention away from the crucial matter of unimpeded access to healthcare by offering glittery trinkets. Recently a relative showed me a Fitbit watch acquired with money which had accumulated in his Advantage plan account. I felt outrage at how Medicare funds are being squandered and was angered at how Advantage plans were depleting precious Medicare funds on nonessentials.
The shortcomings of the Medicare OE process, partly due to the inadequate quality of information presented, requires attention and remedy. There is no rational reason that beneficiaries should not know whether their medications will be covered if they switch Part D plans, even if it means requiring medication prior authorizations during open enrollment before making a final decision. Requiring plans to self-report and post data on their PA requirements, denials and appeal reversals, rather than focusing on beneficiaries’ complaints and the handling of appeals, would provide beneficiaries with better targeted information to inform their choice of Advantage plan.
There is precedent for streamlining decision-making. Enrollees in original Medicare can select among Medigap plans by simply focusing on cost because all plans within each tier must provide identical coverage. Medicare should be easily navigable and assure hassle-free access to healthcare. Greater transparency of actionable information would improve the selection process. Beneficiaries would also benefit by greater standardization of Advantage plans.