post introductory post: all Medicare accepting Providers should also accept all Medicare Advantage Plans

Within a week or two of my introductory post Congress passed the ill-conceived legislation that attacks the PFFS type Medicare Advantage Plan. In my opinion this had more to do with politics and little to do with care for the elderly, for doctors, or for the health of the Medicare Program. In my opinion this was nothing but cynical politics in which under the aegis of rolling back a scheduled ten-percent cut to Medicare physicians, the PFFS type Plan was placed on death row. The physicians could have had that ten-percent cut rolled back, as it was in previous years, without Congress also tolling the death knell for the PFFS plans. If there was anything truly significant about the vote, it was the drama of Senator Edward Kennedy appearing on Capitol Hill, relatively fresh from the surgery to remove his brain tumor, to pass the filibuster-breaking vote. The cynical politics becomes clear, when one sees that this is the first legislation that the Democratic legislature could slip past a Presidential veto. It was all about using propaganda and the wallets of physicians to break the presidential power of veto.

There is a technical matter that goes to the heart of the actual health care delivery via Medicare Advantage plans that has been either forgotten or ignored and ought to be righted by Congressional legislation, if it cannot be righted by a CMS Administrative regulation or by a Presidential edict. This technical matter is the "deeming" process by which health care Providers choose on a voluntary basis to accept or reject participation in any particular Medical Advantage Plan. This matter of deeming is most acute, when it comes to the PFFS type plan. Why? On the one hand the power of the PFFS plan is that it gives the Beneficiary the option to choose any health care Provider -- in theory. The "catch" is that while the Beneficiary may receive services from any Provider that he or she may choose, it is contingent upon the Provider deciding to accept the Terms and Conditions of the particular PFFS Plan (with the exception of emergency care, which is always guaranteed by all PFFS plans). Technically, this contingency exists each and every time the same Beneficiary seeks care, even from the same Provider. (Technically, this contingency exists as well with other type plans such as HMO's and PPO's, although this contingency right is mitigated by the contractual obligations of such network plans.) In reality once a Provider has cared for a Beneficiary and has accepted the PFFS Plan of that Beneficiary, the Provider is likely to accept other Beneficiaries using the same Plan and there is little reason for any Beneficiary to be concerned that the Provider will care for them once, but, not on a regular basis.

That said, there have been some instances in which some Providers have had trouble with some Insurers leading to non-acceptance of some PFFS plans by some Providers. And this is where the technical matter of "deeming" has missed in it's application and where PFFS plans have unfairly been targeted. Remember, there is no permanent contract between Provider and PFFS Insurer. such that however extensive the acceptance of PFFS insurance, each and every instance of insurance is unique, ad hoc, and as such there is a systemic insecurity about the PFFS insurance that ought not exist. It is far too easy for a Provider to decide even whimsically to no longer accept a PFFS Plan. In that sense Congress was right to address the issue, although Congress may not have found the optimal solution in that beginning in 2011 all PFFS plans must be converted into some type of network plan. This is not necessarily a bad idea. Yet, that in itself will not mitigate the expense issues Congress has raised about PFFS plans and about Medicare Advantage Plans altogether. If anything a network plan is more expensive to the insurer and therefore to Medicare, as it is Medicare that foots the expense. Yet, Advantage Plans across the board face deep cuts in funding, thus we see increasing Premiums.

As all Medicare Advantage Plans are Medicare Approved and are ultimately administered by CMS (Center for Medicare and Medicaid Services), it should be required that all Medicare accepting Providers also accept all Medicare Advantage Plans. The "deeming" option should be available on an ad hoc basis to non-Medicare Providers as a way to expand the pool of physicians serving the Medicare population. Medicare Advantage Plans pay the same or more to Providers as simple Medicare. By law Medicare Advantage Plans provide equal or greater coverage and benefits to Beneficiaries of Medicare than does simple Medicare. It makes no sense that Medicare Advantage Plans are not required of acceptance by Providers on an equal basis to simple Medicare. It makes no sense that Medicare Advantage Plans are stigmatized and are not promoted proactively by CMS. CMS should actively educate the Medicare population about Medicare Advantage Plans. And the profound importance of the "OOP" Benefit (Out Of Pocket Maximum Co-payment) that is written into Medicare Advantage Plans, but, not into simple Medicare, is a Benefit that ought to be publicized on the order of an old town crier, "Eleven o'clock and all is well!" After all in these hard economic times, when so many are facing their "Eleventh Hour" and are losing their homes and their bank accounts, the financial protection of the OOP Benefit of the Medicare Advantage Plans is a financial salvation to millions!