Volume 25.06
The National Alliance for Care at Home (“Alliance”), in partnership with KNG Health, has published findings related to deteriorating access by Medicare program beneficiaries to home health care. Key findings include:
- “Since 2019, wait times for a first home health visit have increased by a full day on average, with 10% of patients waiting five days or longer. Over one-third of Medicare beneficiaries discharged from hospitals and referred to home health never receive the care, despite clear clinical need. The effects are stark: mortality rates are 43% higher and 90-day Medicare spending is 5.4% greater for those who go without care.
- Delays in care disproportionately affect underserved communities, exacerbating health disparities. At the same time, CMS payment updates continue to lag inflation, and Medicare Advantage pressures are straining agency viability. This troubling data underscores what providers are experiencing in real time: care is harder to deliver, access is slipping, and lives are at stake.”
As the government continues to encourage Medicare beneficiaries to enroll in Medicare Advantage Plans rather than participate in traditional Medicare program coverage, access to care will not improve (may worsen), payments to agencies will continue to be slow (may be slower), and payments to agencies for services will not improve (may continue to decline). The Medicare Advantage impact, coupled with the inadequate increase in Medicare payments to cover increasing costs of services, requires federal government attention.
The government, if it cares about Medicare program beneficiaries, as well as the costs incurred by the Medicare program, really need to address the many problems with Medicare Advantage (“MA”) in legislation or regulatory controls with substance. The government needs to improve care and reduce costs. Just a few of the problems are:
- While MA plans may have lower premiums than Medicare supplemental plans, they can have higher copays and deductibles, and some enrollees find themselves paying more in the long run, especially if they have serious illnesses.
- MA plans often require prior authorization for certain procedures, which can delay or even deny necessary care, leading to frustration and dissatisfaction.
- MA plans have network restrictions, meaning that enrollees are limited to a specific network of doctors and hospitals. This can be a major issue for individuals who want to maintain their existing relationships with their doctors and providers, or who travel frequently and need access to care outside their plan’s network.
- If a doctor or hospital leaves the MA plan’s network, enrollees may have to switch to a different plan or find new providers, which can be a stressful and disruptive process.
- Some enrollees feel “trapped” in their MA plan because they are unable to easily switch back to Original Medicare due to limitations on enrollment periods or fear of losing their established relationships with their doctors.
- In many cases payments to the serving agency are not timely thereby contributing to increasing financial difficulties of the agency.
It is important to remember, Medicare Advantage Plans are in the business of making a profit. Denying or delaying access, denying payments for services rendered, and delaying payment to agencies all contribute to the ability of the insurer to generate a profit from services. Amazingly, Medicare Advantage Plans are not expected to save the government money compared to traditional Medicare coverage. Studies by the Medicare Payment Advisory Commission (“MedPAC”) and the Center for Economic and Policy Research (“CEPR”) indicate that MA plans often cost the government more. In 2024, the Institute for Public Policy and Government Service reported that Medicare Advantage costs taxpayers 22% more per-enrollee. This report included “As Medicare Advantage becomes increasingly expensive, the Medicare program continues to face funding challenges.”
In May 2024, the Center for Medicare Advocacy released an article entitled, “Medicare Advantage Industry Will Focus on Profits Over Benefits in 2025.” https://medicareadvocacy.org/medicare-advantage-industry-will-focus-on-profits/.
Unfortunately, Medicare beneficiaries are inundated with promotions and marketing efforts to switch from traditional Medicare coverage to MA. Perhaps it is time for providers (all types of providers) to join together to market directly to seniors about retaining traditional Medicare coverage or switching from their MA coverage to traditional Medicare. Regardless, the heavy focus on securing MA coverage needs increasing attention by healthcare associations and the federal government, directed at making appropriate care available to Medicare beneficiaries while controlling total costs of the program.
NASBA MEMBERSHIP RENEWED THROUGH JUNE 30, 2026
The National Registry of CPE Sponsors (“NASBA”) has approved The Health Group, LLC as a sponsor of continuing professional education (“CPE”) through June 30, 2026. As a sponsor, The Health Group, LLC confirms continuous compliance with the “Statement of Standards for Continuing Education (CPE) Programs” and the program requirements of the National Registry of CPE Sponsors.