Prairie Doc Perspective Week of November 26th, 2023
By Tom Dean, MD
TV is flooded these days with commercials encouraging everyone to sign up for Medicare Advantage(MA). What is MA and why are they doing this?
First of all, a bit of history. For more than 30 years Congress has debated whether the private insurance industry could deliver Medicare benefits more efficiently than the federal government. In 2003 these efforts evolved into what is now known as Medicare Part C or, more commonly, Medicare Advantage (MA).
MA plans, operated by private insurance companies, cover services provided by Parts A & B of traditional fee-for-service Medicare (FFS) as well as most of the costs traditionally covered by Medicare supplement policies. Many, but not all, include drug coverage traditionally covered by Medicare Part D plans. Some MA plans include services not usually provided by Medicare such as dental and vision coverage.
How is MA financed? Each MA plan receives from the government a fixed payment to cover the services provided. The amount of this payment, known as the “benchmark”, is determined on a county-by-county basis. The amount of the benchmark is based on data indicating what traditional fee-for-service Medicare would expect to spend providing care for the residents of that particular county. MA plans consider the amount of the benchmark and then decide if they will offer a plan in that area. This is why the ads always ask you to provide your zip code when you are looking for an MA plan. If they decide to offer a plan but decide the benchmark payment will not cover the full cost of the care they may charge the enrollee an additional premium.
In recent years MA plans have grown rapidly. They now cover more than 50% of the Medicare eligible population. A broader range of benefits and lower out of pocket costs have been the primary drivers of this growth. Additionally, more MA plans have become available, some in areas where plans were not previously offered. In the original planning for MA it was hoped that providing a profit incentive would lead plans to find less costly ways to provide care and thereby save the government money. Unfortunately, that has not happened and, for most of its history, MA has cost the government more than traditional FFS Medicare.
So, what is the downside? Broader benefits and decreased out-of-pocket costs would seem to be powerful incentive to switch from FFS to MA. In fact that is what has happened. Many enrollees have been pleased with the switch. There are, however, reasons to be cautious.
Fixed limits on what they will be paid provide an incentive for plans to limit what they spend. In general they have been successful in doing this and for most plans MA has been a highly profitable undertaking – a fact which accounts for the multitude of TV ads we see.
To control costs some plans cover only limited networks of medical providers. This has meant that enrollees had to leave familiar doctors, hospitals, etc. Medical providers have complained that MA plans were much harder to work with than FFS. Some have complained about delayed and insufficient payment, frequent requirements for pre-authorization for procedures, etc. This has especially been a problem for small rural hospitals. Most of these are enrolled in the Critical Access Hospital (CAH) program which provides special payment procedures to aid in their survival. In many cases MA plans have refused to recognize these special payments leaving CAH facilities even more financially stressed than before. Overall frustration with inadequate MA payment has caused at least one mid-sized hospital in South Dakota to totally withdraw from participation in the program.
Selecting health care coverage is both difficult and very important. We are now in the “open enrollment” period for Medicare. This is a time when eligible folks can decide if they want traditional FFS Medicare or a MA plan. If they choose the latter they then have to select the plan that best fits their needs. Many people have been well served by MA plans but they need to ask about network requirements, extent of coverage, additional premiums, etc. This is an important decision and one that should receive careful thought and attention.
Tom Dean, MD of Wessington Springs, South Dakota is a contributing Prairie Doc® columnist who has practiced family medicine for more than 38 years. He served as a member of the Medicare Payment Advisory Commission. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.
Prairie Doc Perspective Week of November 12th, 2023
“Stay Safe Out There”
By Debra Johnston, MD
I learned a lot of statistics back in medical school, many of which are outdated and long since forgotten. A few still haunt me, though. One example: over 50% of seniors who suffered a broken hip would be in a nursing home, or in their grave, within a year.
The odds are somewhat better today, but a hip fracture is still a very serious event, especially if your health, or your independence, is already compromised. We may be better at helping people recover, but the best strategy is not break that hip in the first place.
Another lesson that has stayed with me from those days involves a gentleman who had spent his weekend baling hay despite his terrible back pain. He was able to do so with the assistance of handfuls of Tylenol, and a beer or two at the end of each long hot day. Little did he realize he was poisoning himself with all that acetaminophen. By Wednesday, he was on a ventilator in our ICU, in need of a new liver. His story is still common; acetaminophen toxicity is the most common cause for liver transplantation in the United States, and the second most common cause world wide. At appropriate doses, Tylenol is extremely safe. It’s just really easy to exceed those doses if you aren’t vigilant.
I don’t think any American makes it into adulthood without a story or two about a motor vehicle accident involving someone they knew. After all, between 2 and 3 million of our countrymen are injured on our roads each year. About 40,000 of us die, and many others find their lives permanently changed by the injuries they sustain. Nearly 200 Americans die every day from traumatic brain injuries, but even those who survive the initial event face a grim future. If their injury is severe enough to require an inpatient rehabilitation stay, an additional 1 in 5 people die within the next 5 years. Nearly 60% of the others face at least moderate disability.
In 2019, unintentional injuries were the leading cause of death for Americans between the ages of 1 and 44, and the 3rd leading cause overall. Poisoning, motor vehicle accidents, and falls account for the vast majority of those deaths, with all other causes, including suffocation, drowning, and fire making up about 15%.
I think I’ll keep nagging people about getting their calcium, about wearing their seatbelts and helmets, and about locking up their firearms. In fact, I’m going to nag YOU right now: go check the batteries in your smoke detectors. Put your phone where it can’t tempt you when you get behind the wheel. Slow down a little. Do your part to protect yourself, your family, and your neighbors.
Let’s keep ourselves, and each other, safe out there, people.
Debra Johnson, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show providing health information based on science, built on trust for 22 Seasons, streaming live on Facebook most Thursdays at 7 p.m. central.
Prairie Doc Perspective Week of November 5th, 2023
By K. A. Bartholomew, MD
How much blood flows through your joints? Would you be surprised if I told you “None”?
That’s right! Inside the joint there is a clear, viscous, slippery fluid that lubricates the joint surface, but no red blood flows inside the joint. Doctors do not want to see blood in a joint. When there is blood inside a joint it is usually because of trauma. That means tissue has been injured and blood vessels have been broken, bleeding into the clear cavity.
“How,” you may ask, “can a joint get oxygen and nutrition if there is no blood in the joint?”
Articular (joint) cartilage has no direct blood supply. There is plenty of blood flowing “around” a joint, bringing oxygen, glucose, vitamins and minerals to the area and clearing out waste products, but these must diffuse through tissue membranes to get in to and out of the joint space. The cartilage receives its nutrition and oxygen from the clear joint fluid. When the joint is “loaded” with pressure, some fluid is squeezed out of the cartilage, and when the pressure is released, fluid flows back in carrying oxygen and nutrients with it.
The interesting thing is that this diffusion goes very slowly if that joint is not moving and pumping on tissue. This is why exercise is so crucial to joint health, just like it is crucial to all tissue health. It becomes even more so when that joint is injured. There must be good circulation and activity to absorb old, clotted blood inside an injured joint, “draining” the waste products and replacing them with the clear lubricating fluid. Additionally, damaged tissue heals but leaves scar tissue behind. If that scar tissue is not stretched and exercised, that joint will never regain its mobility.
Likewise, an injured or arthritic joint may hurt when you exercise, but without exercise it cannot maintain its internal health. As scar tissue forms from the arthritic damage to the cartilage, the joint moves less freely, like a rusty hinge. But exercise “oils” the joint, so to speak, creating lubrication while maintaining range of motion. This is not unlike that old car behind the barn that has not been driven for decades. It will have an engine that is frozen with rust, yet the antique Model A that your friend drives every Sunday still purrs along because it has been used - moved, maintained, and lubricated. Your joints need the same.
Kenneth A. Bartholomew, M.D. is a contributing Prairie Doc® columnist. He lives in Fort Pierre, South Dakota and serves on the Healing Words Foundation Board of Directors, a 501c3 which provides funding for Prairie Doc® programs. He specializes in family medicine with more than 40 years of experience. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming live on Facebook most Thursdays at 7 p.m. central