>I'm talking about Medicare Advantage, not Medicare Part D. Most Medicare Advantage plans do include a Part D plan, but not all do.

I would have thought 9 out of 10 advantage plans have part D drug coverage but its actually 82% at an average cost of $40/month.

>Medicare Advantage consistently outperforms Original Medicare on medical outcomes, not just on patient satisfaction.

Outcomes is a buzz word, if you want to talk Star Ratings and Quality Metrics, then we can begin to discuss what "outcomes" really mean.

Just one example where a quality metric has both positive and negative patient effects simultaneously: say I'm Blue Cross Blue Shield, thru MTM I somehow manage to get all my Medicare Advantage Part D Chronic Care Patients to switch an average of 10 Rx/patient from 30 day to 90 day fills.

Its these little things inherent in the Star Rating/Quality Measure system that people regularly refer to as patient "outcomes". In my example, the Blue Cross Blue Star Star Rating might even go to 5 allowing me to sell insurance year round. Why? It starts with medication related incidents costing billions/year and resulting in millions of hospitalizations and that being some of the lowest hanging fruit to correct, so "medication adherence" is heavily weighted in Star Ratings, and somewhere there is a study concluding 90 day fill improve medication adherence by x% over 30 day fill (i.e. improved outcome). It all sounds great until you peel back the layers and find a doctor who refuses to change the script because morally the doctor wants to see that patient every 30 or 60 days (again these are all Chronic Care Patients so diabetes, blood pressure, cholesterol, etc...) before writing a refill. When these objections regularly occur from doctors, insurance has deemed them to expensive and drops them from the network, and as I stated in my initial post those patients will regularly be redirected to a practice owned by the insurer themselves.

Now in all fairness we all know there are doctors who do in fact milk the system with unnecessary patient visits but it is undeniable from the court cases by groups of doctors who have been dropped against the insurers and the reactions of patients losing a doctor they know and trust, there is very unsavory behavior by insurers.

Here is my final diatribe on my bone to pick with "outcomes", naturally one way to drive down costs care (thus improve Star Ratings and outcomes) is switching from name brand to generic. However, even when doctors feel a generic may be fine they may not want to change a therapy in instance when the patient has been on a continuous therapy successfully managing their chronic care condition just to save a few dollars, improve the insurers Star Rating, and claim better patient outcome. Though this debatable issue becomes a clear problem when insurers start pushing the doctor (and even the patient thru cold calling) to change the Rx to a generic that is clinically proven to be harmful to patients to save money (which may actually be happening with the diabetes Statin therapy).

> Outcomes is a buzz word, if you want to talk Star Ratings and Quality Metrics, then we can begin to discuss what "outcomes" really mean

If you want to talk about how metrics are imperfect, fine, but you can't claim that Original Medicare is somehow better unless you actually propose some concrete metrics on which it actually does outperform Medicare Advantage. As it stands, Medicare Advantage consistently beats Original Medicare on pretty much every metric you can conceive of.

Every single Advantage patient is enrolled in "oringinal medicare" parts A and B, the only difference is those parts are administered by private insurance...and all the additional benefits and cost savings by law on these plans. That is to say the benefits and cost savings of advantage aren't there because the private market they are mandated.

Take my 1 example MTM, Medicare Advantage patients don't get that benefit because the private market is driving competition and better care, it's because by law the Avantage plans have to provide MTM under penalty of losing their Medicare contacts.

I'm not denying Avantage is better than original Medicare, but to claim the reason Advantage may be better is insurance companies and not the legally mandated benefits and costs of Advantage plans isn't good faith, especially when you already minimized >80% of the patients get mandated drug coverage. Yes it's good but is has nothing to do with insurance creating the market conditions that created the drug coverage, its law and subsidies. Though it will become clearer as the insurance continues to consolidate and Medicare patients will only be able to go to doctors, hospitals and pharmacies owned by the insurer, because that's where it's going for Medicare Avantage patients, costs will go down but I'll be damned if I call that a "good outcome".

> Every single Advantage patient is enrolled in "oringinal medicare" parts A and B, the only difference is those parts are administered by private insurance

Again, it seems you're confused about what Medicare Advantage is. Medicare Advantage essentially replaces all Medicare coverage - parts A, B, and (usually) D. So no, Part C patients are not enrolled in Original Medicare in any sense. They are enrolled in Medicare, but not Original Medicare.

> Yes it's good but is has nothing to do with insurance creating the market conditions that created the drug coverage,

I'm not talking about drug coverage. Medicare Advantage provides a superior (in every measurable sense) way to obtain Part A and B benefits than Original Medicare does. That has nothing to do with drug coverage.

> its law and subsidies.

It's not a matter of "subsidies". Medicare Advantage is not subsidized by the government. The government pays private insurers a fixed amount that corresponds to what Original Medicare would "receive" for each patient, but that's not a subsidy. And when we say that Medicare Advantage outperforms Original Medicare on cost, we're saying that Medicare Advantage is able to achieve better outcomes for the same amount of money.

If you think that's just a fluke, then look at Medicaid. The same pattern holds with Medicaid, where privately managed plans again consistently outperform the government plans, even though the array of requirements differs widely.

> especially when you already minimized >80% of the patients get mandated drug coverage.

The drug coverage isn't "mandated" for Medicare Advantage patients, any more than it is "mandated" for Original Medicare patients who enroll in a Part D plan or a Medigap plan. Medicare Advantage patients who don't receive prescription coverage can get a Part D plan just like Original Medicare patients can.

Maybe you're trying to say that there's a beneficial selection occurring, but that's also wrong. Part D is well-segemented

That argument would basically boil down to "Medicare Advantage is only better than Original Medicare because most Medicare Advantage patients receive drug coverage", which makes no sense because (a) the same companies provide Medicare Advantage and Part D benefits (and oftentimes using same plans), and (b) Medicare Advantage provides superior coverage and quality (and at a lower price) when compared to Part D enrollees with the same prescription coverage.

Honestly, the existence of Part D is, if anything, proof positive of this effect, because it makes it so easy to tease out the difference between receiving Part A/B coverage through Original Medicare and receiving equivalent coverage through Medicare Advantage.

> Though it will become clearer as the insurance continues to consolidate and Medicare patients will only be able to go to doctors, hospitals and pharmacies owned by the insurer, because that's where it's going for Medicare Avantage patients

That's the way the entire industry is headed as a direct result of the ACA. But even that's still a lot better than Original Medicare where patients struggle to get appointments at all.

>The government pays private insurers a fixed amount that corresponds to what Original Medicare would "receive" for each patient, but that's not a subsidy.

Define it however you want, it leads to watered down care. Naturally, the Insurers have incentive to identify the primary care physicians who don't see their patients (especially chronic care) or don't order referrals to specialists. Have you followed a single lawsuit against the Medicare Advantage plans by physicians and physician groups? Insurers identify these practices (the ones that have minimized costs through watered down care) buy them/cancel other physicians out of the networks/funnel remaining patients to the doctor.

Let me ask you, how do you think an Advantage patient can set an appointment so easily when the networks have narrowed (less physicians, less patient choice) and the overall patients/doctor in network increases? Its because systematically the complicated chronic care patients are seeing the doctor less and less and the network doctors have more time to spread around and set appointments in 24-48 hours (you say improved outcome, I say yes for many but also watered down care for many). I will admit, patients like seeing their doctor in 24-48 hours and like seeing them 1-2 a year instead of 4-6, its convenient and cost them less (in co-pays if nothing else), but its still watered down care, especially to the chronic care Medicare Advantage patients.

I will predict this as well...the next step in all this is for Pharmacists to be labeled providers (can bill CMS under Parts A, B, C) and they will begin replacing physicians as the providers for Medicare Advantage chronic care patients. Again outcomes will go up because the patients are actually being seen and the Chronic Care CPT code will be billed/reflected on their EHR, but the care will be watered down (patients now forced to see pharmacists instead of doctors for chronic care management), but hey costs will go down right? Even the patients will be happy because they can just walk in to a pharmacy anytime without an appointment and see a pharmacist, plus the copay will probably be cheaper, again you/Insurers/even patients can say "improved outcomes", I'll maintain less choice and watered down care.

> Define it however you want, it leads to watered down care

I can't even follow what you're trying to say anymore, because you're conflating unrelated topics. And again, you're still not really actually defining the metrics that you care about, so it's hard to respond because you're not offering any concrete and systematic method for evaluating effectiveness. I've mentioned a few metrics (which happen to be the industry-standard, first-order metrics). You don't have to agree with them, but if you're going to dismiss them, then you need to propose something else or it's impossible to engage with what amounts to a flurry of anecdotal problems. (Anecdotal doesn't mean that they're not real or important, but it does mean that there isn't a framework for discussing them).

> Its because systematically the complicated chronic care patients are seeing the doctor less and less and the network doctors have more time to spread around and set appointments in 24-48 hours (you say improved outcome, I say yes for many but also watered down care for many). I will admit, patients like seeing their doctor in 24-48 hours and like seeing them 1-2 a year instead of 4-6, its convenient and cost them less (in co-pays if nothing else), but its still watered down care, especially to the chronic care Medicare Advantage patients.

This is completely and utterly wrong. I founded a heath-tech company aimed at coordinating care for this exact space. That statement is completely off-base.

>I've mentioned a few metrics (which happen to be the industry-standard, first-order metrics).

What metrics have you mentioned at all? You claim original Medicare patients can't get appointments and Advantage can, fine I'll chalk that up as a metric/outcome impacting insurance star ratings, but you ignore the fact people like advantage 8 out of 10 because they get drug coverage, that is not unrelated. Tell you what take away Part D drug coverage from 8 of 10 Advantage plans do you think the patients will still be happy with Advantage over Original Medicare (see my links below before you answer that the links below belie your statments appoint access/appointments between Advantage and Original)?

Moreover, Advanatage and Original Medicare patients report similar experience in getting primary care appointments, and in fact Original Medicare out does Advantage in getting Specialty appointments (only by 2% but still) [1] and the chart [2].

You completely ignored the metrics about I mention about: [1] 30 to 90 Rx transfers; or [2] Rx transfer to generics (including Statin which for Medicare Advantage Diabetes patients which is clinically proven fatal in a few cases out of every million).

[1] http://kff.org/medicare/issue-brief/medicare-patients-access...

[2] http://kaiserfamilyfoundation.files.wordpress.com/2013/12/85...

>This is completely and utterly wrong.

Please show me the data supporting any notion that on average Medicare Advantage patients have larger doctor networks than Original.

Alright, I can't continue this, because it's too dizzying to try and follow what you're saying, as it changes with every comment.

You were the one who brought up costs and patient outcomes:

> get in the middle and increase costs while reducing patient outcomes.

So I responded to that claim by talking about Medicare Advantage (Part C), at which point you bring up Part D, confusing it for Part C:

> Patients like Medicare Part D because millions of patients couldn't afford their drugs and now they can, not because of insurance companies or the market is privatized.

After I explain that, no, I'm talking about Part C (which provides Part A/B benefits) as opposed to Part D, and that the advantages to Part C are lower wait times and higher-quality doctors, which both lead to better outcomes, you go back and say that outcomes (which you initially talked about) aren't necessarily good, illustrated with an anecode:

> Outcomes is a buzz word... Just one example where a quality metric has both positive and negative patient effects simultaneously...

but don't actually propose any alternative metric to measure instead. I asked you to do that, and you demur, talking about costs but again dismissing outcomes, along with some other factual inaccuracies about Medicare

> Every single Advantage patient is enrolled in "oringinal medicare" parts A and B... additional benefits and cost savings by law.... but I'll be damned if I call that a "good outcome".

I correct those factual inaccuracies, and then you bring up insurance networks (which are related, but not the same as quality of care), and also go back to talking about wait times. You also say that this is "watered-down care", but don't actually define what that means (the only thing that's clear is that you don't mean "medical outcomes"):

> Define it however you want, it leads to watered down care.... you say improved outcome, I say yes for many but also watered down care for many

I say that no, your statement about wait times is wrong, and remind you that you still haven't defined the metrics that you're actually using to measure quality or effectiveness of medical outcomes. You respond by complaining that I haven't addressed your example of a bad metric:

> You completely ignored the metrics about I mention about: [1] 30 to 90 Rx transfers; or [2] Rx transfer to generics (including Statin which for Medicare Advantage Diabetes patients which is clinically proven fatal in a few cases out of every million).

...except that I'm actually willing to engage your point that some metrics are flawed - my whole question for you is what you're using to define medical quality if you're not using the industry-standard measures?

And to top it all off, you respond to my comment about wait times by saying:

> Please show me the data supporting any notion that on average Medicare Advantage patients have larger doctor networks than Original.

Except that I never said anything about larger doctor networks. Nor, for that matter, did you! I was responding to your claim about wait times, which is not the same thing as the size of the network.

I don't mind correcting misunderstandings about the fundamental structure of Medicare, because I understand that it's rather esoteric and most people here don't have any experience with it. But doing that while also trying to chase your goalposts in circles is immensely frustrating, and I don't have the time for that. Sorry.

It's sad because I am frustrated as well, and I believe we likely could have had a more civil and informative conversation, maybe in person or another medium. I'll leave it at this myself:

>So I responded to that claim by talking about Medicare Advantage (Part C), at which point you bring up Part D, confusing it for Part C:

You used Advantage and I did respond using Part D, but its not for any misunderstanding. Literally there is no Part D without Advantage/Part C, and Part D is included in 82% of all Advantage/Part C Plans. Moreover, the rule is that Advantage Plans include Part D, it is the exception for Advantage to not have Part D. The truth is this point doesn't even matter, It just keeps getting in the way of proper discourse, it makes me believe you are minimizing the importance of drug coverage in Advantage Plans and it makes you think I don't understand the structure of Medicare.

>And to top it all off, you respond to my comment about wait times by saying:

I also responded to your comment about wait times with CMS patient data that shows Advantage/Original patients are equally satisfied for primary care wait times and Original are more satisfied with specialty wait times.

Its clear you know a good deal about Medicare, but I question your intimate knowledge of how the following and is gamed in the interest of claiming better medical/patient outcomes: Star Ratings, Quality Measures, MACRA, MTM, Managed Care, ACO, CPT codes, etc...

>my whole question for you is what you're using to define medical quality if you're not using the industry-standard measures?

I think that is a very fair question, because I didn't expressly state a new or better set of measures/metrics/outcomes, mostly because I don't believe in a one size fits all solution to care, it must be individualized (i.e. its not always an improved outcome to switch a Chronic Care Advantage patient to a Statin; or even though 90 day Rx may improve medication adherence of patients on average it also shows patients show up to the doctor less so in the case of Chronic Care patients the 90 day Rx should be a quality measure/improved outcome). However, in a one size fits all approach I would say it is a bad patient outcome when Insurers shrink their networks, patients lose their doctor(s), and patients are funneled to Insurance owned practices (I think you issue is that those measures/outcomes are unrelated to "quality of care" as you put it, but neither are many of the current measures most of which are based on costs or medication adherence, though I would argue the quality of care has gone down when a patient loses their doctor of years).