MedPod Today: Medicare Advantage Woes, Double Billing, NHPI Health Disparities

The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody. Welcome to MedPod Today, the podcast series where MedPage Today reporters share deeper insights into the week’s biggest healthcare stories. I’m your host, Rachael Robertson.

Today, we’re talking with Cheryl Clark about her recent interview with the head of the agency that advises Congress about Medicare policy. Then we’ll hear about some instances of double billing from Jennifer Henderson. After that, I’ll share the story of one physician-scientist changing the narrative surrounding NHPI health disparities.

One of the most well-read pieces on our site last week was an interview Cheryl Clark did with Michael Chernew. Chernew is a Harvard professor who chairs the Medicare Payment Advisory Commission. Because Medicare Advantage enrollment has been growing so rapidly in recent years, and serious problems about it are emerging, Cheryl wanted to know if traditional Medicare will still be an option, or whether we’ll all have to be on Medicare Advantage at some point in the future. Cheryl is here to tell us more.

So Cheryl, what is the difference between Medicare Advantage and Medicare? Why is there a concern that Medicare might go away?

Cheryl Clark: Well, traditional Medicare covers doctor visits, hospitalization, imaging labs, and other services and allows you to see any provider who takes Medicare anywhere in the country, but not prescription drugs. Medicare Advantage plans are run by private companies that receive a capitated sum each month to bundle services, including drugs, and they throw in other services that Medicare doesn’t cover, like vision and hearing. And Medicare Advantage plans now cover a majority of beneficiaries, which is a huge jump from years ago.

So the idea behind MA is sound: you get coordinated care from providers who talk with each other, the patient is less likely to receive low-value, potentially harmful care. And these MA plans are great for healthy people. But there’s a catch – and a lot of people don’t understand this: MA plans require patients to just use their provider networks, often called a “narrow network,” and that can mean long wait times. They often do not include specialization centers for conditions like cancer. And many of these plans use AI-generated algorithms to deny coverage.

Robertson: You know, it makes sense that some people will be drawn to Medicare Advantage plans only to find out later the hard way that the plan doesn’t actually cover all of their needs.

Clark: Exactly. Many people I know didn’t even know they were in an MA plan. They enrolled when they were healthy, often persuaded by brokers who, as it turns out, get high commissions for enrolling beneficiaries into these plans. Now as they get older, they realize they never read the fine print.

There are hundreds of dollars of hospitalization co-pays, the drugs they need aren’t in the formulary, or they’ll have to pay out-of-pocket for a specialist. Plus, some MA plans have been defrauding the Medicare trust fund, claiming their enrollees are much sicker than they really are in order to generate higher Medicare payments to increase their profits. In fact, this year MA plans are expected to receive $88 billion more than Medicare would have spent if patients had been in traditional Medicare.

Chernew told me that MA covers 90% of beneficiaries in parts of the country even now. So I asked him if every beneficiary would eventually have no choice, but Medicare Advantage, and what should policymakers do to fix these problems?

Robertson: What did he say?

Clark: Well, he didn’t answer some of these questions directly. He said that traditional Medicare will be available for the foreseeable future, but he didn’t really say what that was. More importantly, he said repeatedly that Medicare Advantage plans deliver better care than traditional Medicare, something a growing number of patients and doctors disagree with vehemently. He acknowledged the need for Medicare to address these concerns about whether the plans are working as they should. One solution might be to cut MA plan rates, he said, but he held fast to the idea that patients should know they are making a trade off when they enroll – and I’m not sure they always do.

Robertson: We got a lot of interesting responses to your piece. What were you hearing from doctors and other healthcare professionals?

Clark: Almost universally, they were extremely critical of Chernew’s responses, saying he dodged the questions. As providers, they wouldn’t enroll in an MA plan ever. Here’s a sample: “Having practiced medicine in Iowa as a pulmonologist for the past 29 years and planning on retiring in a year, I in no way, would consider an MA plan. I am daily curtailed in my ability to care for my patients.” Several noted that Chernew didn’t know what kind of a plan his own father had, suggesting that he, as one commenter noted, doesn’t get it at all.

Robertson: Thank you so much, Cheryl.

Clark: Thanks, Rachael.

Robertson: Recently MedPage Today found out about several instances in which patients noticed interesting signs posted at their physician’s office. The sign said that patients may be billed twice if they raise a separate issue beyond the original scope or purpose of their visit. Jennifer Henderson looked into the issue and is here in the studio to tell us what she found.

So Jennifer, what is happening with these signs? What are they?

Jennifer Henderson: So one of the signs was posted at a primary care clinic in Charlotte, North Carolina – Atrium Health Primary Care Mountain Island. And a MedPage Today reader in San Antonio, Texas flagged a similar sign at his granddaughter’s pediatrician’s office, which he didn’t name. In Boston, a local woman was billed twice for a single primary care visit by Mass General Brigham, according to reporting from WCVB-TV. And patient advocates say they’ve been hearing about these particular issues for years. Technically, physicians are within their rights to charge separately.

Robertson: So what are providers saying about this practice?

Henderson: The practice of separate billing appears to be commonplace among healthcare providers in a range of settings. Here’s what the American Academy of Family Physicians told me in an email: “For example, when a patient has an annual wellness visit or physical, and the physician addresses something else, the physician would bill for an office visit in addition to the physical,” and, “Cost-sharing is waived for the preventive service, but the patient may have a charge for the office visit.”

The American Academy of Pediatrics also told MedPage Today in an email that separate billing is “not a new practice,” rather a “broader reflection” of financial pressures affecting pediatric practices. These pressures include rising costs without increases in payment and the need to charge for additional services beyond the scope of traditional wellness visits.

For its part, Atrium Health said that “separate billing has been a common practice at healthcare systems around the country for quite some time,” in an emailed statement. And the health system cited an example of “discussing a new skin rash or a pain concern during an annual physical exam.” Mass General Brigham did not return MedPage Today’s request for comment on the issue of separate billing.

Robertson: What are the concerns with separate billing?

Henderson: So Caitlin Donovan, senior director at the National Patient Advocate Foundation, told MedPage Today that she has heard about the issue repeatedly over the last 10 years. While the top concern she usually hears about is finance, a close second is patients wanting to know how to get their doctor to listen to them. “This kind of falls in the intersection,” she said. Separate billing may give patients the impression that an office visit with their physician is simply a financial transaction, or that they can’t raise important health issues during this time.

Robertson: Thank you for this report, Jennifer.

Henderson: Thanks, Rachael.

Kekoa Taparra already has a PhD and an MD – and he’ll have an MPH later this year. While relatively early in his career, Taparra is already making waves in the medical field. Not to mention that he’s the first Native Hawaiian to earn both an MD and PhD. Rachael wrote a profile of Taparra and she’s going to share more about him and his work.

So Rachael, let’s start with a bit about Taparra – is he from Hawaii? Has he always wanted to be a triple threat?

Robertson: Taparra definitely didn’t always know that he wanted to be a doctor. He grew up on O’ahu and none of his family worked in medicine. In fact, the first doctor he spoke with other than his pediatrician was his PhD advisor at Johns Hopkins University, Dr. Phuoc Tran. Tran is a physician-scientist and encouraged Taparra to do the same thing after hearing Taparra talk about how he lost nine of his family members to cancer.

Taparra completed his PhD in cellular and molecular medicine and then he moved on to his MD at the Mayo Clinic Alix School of Medicine in Minnesota. So now, Taparra is currently doing his fellowship at Stanford Medicine and is working on his MPH virtually through Hawai’i Pacific University. He’s the first Native Hawaiian to have both an MD and a PhD, but he always points out that he still comes from a strong cultural lineage of healers and that Native Hawaiians have a “deep, rich culture of people who have learned and passed down knowledge in other ways.”

Henderson: Tell us more about his research. What are some of his contributions so far?

Robertson: Taparra and another one of his mentors Dr. Curtiland Deville, who runs the Johns Hopkins Proton Therapy Center, published a pivotal piece in the Journal of Oncology Practice. It detailed the cultural and historical context of cancer disparities for Native Hawaiian and Pacific Islander – NHPI – populations. The article explains how colonization impacts the current realities of NHPI folks and how that history continues to play out today. For instance, in Hawaii, Native Hawaiians are most likely to be uninsured and impoverished, which makes it especially hard to seek preventative care. The piece they wrote was chosen as the cover story for that issue. And now, Taparra has done a lot more work on NHPI health disparities in addition to his cancer research.

Another common theme in his work is data disaggregation. Up until 1997, Asian Americans and NHPI were lumped together, which Taparra said does a disservice to both groups, which face different kinds of disparities. For instance, in one of his studies, he found that compared to white patients, NHPI folks had inferior survival outcomes for common cancers, while Asians had better outcomes. Disaggregated data helps to bring those nuances to light.

Taparra told me it’s vital to “actually go into communities and engage with community members and incorporate them into the research practices so that we can deliver this optimized care in a culturally competent way that really leverages collaboration within the community.”

Henderson: It sounds like Taparra has connected his identity to his research.

Robertson: Taparra didn’t have NHPI mentors himself. I mean, he found meaningful connections with other mentors. But now he gets to be the NHPI mentor for earlier career students and residents himself. He created Taparra Labs, which is a team of mostly Native Hawaiian and Pacific Islander undergraduate, graduate, and medical students. The lab describes itself on its website as working “to further our understandings of the unique health disparities of Pacific Islanders in order to improve health outcomes for our future patients.”

I spoke with two of Taparra’s mentees and members of his lab who are both NHPI as well, and they had nothing but positive things to say about him. One said, “It was very, very comforting to know that there are people like me, who have very similar interests and goals,” and “you feel like you’re less alone, from a cultural perspective, and from a mission perspective – that there are other people out there trying to fight the same fight.”

Ultimately, Taparra hopes that his work will eventually lead him back home to Hawaii. But for now, he’s growing a community of NHPI researchers so that more people see themselves represented and understood in medicine.

Henderson: Thanks, Rachael, for your reporting.

Robertson: And that’s it for today. If you liked what you heard, leave us a review (on Apple or Spotify) wherever you listen to podcasts, and hit subscribe if you have not already. See you again soon.

This episode was hosted and produced by me, Rachael Robertson. Sound engineering by Greg Laub. Our guests were MedPage Today reporters Cheryl Clark, Jennifer Henderson, and Rachael Robertson. Links to their stories are in the show notes. MedPod Today is a production of MedPage Today. For more information about the show, check out medpagetoday.com/podcasts.

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