Value-based care has become a hot topic in the health care industry. The model of paying providers bonuses for better patient health outcomes and penalizing them for poor outcomes may seem like a great idea and one that would encourage a more holistic approach to patient care. Some health care experts have concerns about what this means for people on Medicare Advantage (MA), though; specifically, there may be more focus on costs and less focus on quality. Janice Horowitz, author of Health Your Self, has three primary concerns when it comes to value-based care in MA plans:

  1. Restrictions on where you can go for treatment – Value-based care is built on having one general primary-care physician from the plan’s list and only being referred to specialists within the plan when it meets the plan’s guidelines. If the specialist the patient wants to see is not part of his/her MA plan, they either cannot see that specialist, or will have to pay extra.
  2. The “gatekeeper” system – MA plans typically require patients to see clinicians who are not doctors (think nurse practitioners, physician assistants, community health workers, etc.) because they are paid less. Having patients see alternative health care providers is less expensive for the plan and could mean the quality of care provided is less than if seen by a traditional doctor. However, clinicians may be more accessible than doctors and still provide adequate care.
  3. Certain prescription drugs might not be covered – frequently plans prioritize generic drugs over brand names, and are insistent on older, more established drugs as opposed to newer ones.

There are several steps patients can take to help avoid some of these value-based care issues if they or a family member are a Medicare beneficiary:

  1. Use Medicare’s online Plan Finder to help sort through the multiple MA plans.
  2. Study the rules of any plans you are considering to find out how much you will l have to pay for services you might need.
  3. Prior to enrolling, find out what the plan does to keep you healthy and what your experience will be if you get sick. It is also a good idea to check whether your current doctors and hospitals are covered under the plan or if you’ll need to switch.
  4. Call the Medicare Rights Center’s free consumer helpline at 800-333-4414 to speak with a counselor about any questions that you may have.
  5. You can also call your State Health Insurance Assistance Program (SHIP) for free Medicare counseling.
  6. File an appeal through Medicare’s process if you believe you’ve been denied care that should have been covered under Medicare or if you’ve been denied a medication prescribed by your doctor.

For more information on value-based care, read the full story on Next Avenue’s website: https://www.nextavenue.org/value-based-health-care-costly-for-medicare/