Navigating the Medical Maze: Frustration Mounts as Medicare Choices Overwhelm

By Julie Woodward

Navigating the American healthcare system is very, very difficult, especially when you don’t have employer coverage or public assistance.

I’ve listened to the frustration of so many new retirees at my workshops they they’re confronted with a massive amount of Medicare information for the first time. It’s overwhelming what they have to absorb before they can choose the best plan for their specific health issues and pocketbook at this stage in their lives. Some are angry at our system, a few can barely hold back tears.

Apart from how much there is to learn and the lack of transparency in every component of medical care, a fair number of hidden and unpredictable industry practices compound the difficulties of medical decision-making. We no longer know what to expect from our coverage when even simple terms like “hospital,” “out-of-pocket medications” or “skilled nursing” don’t guarantee the cost or extent of services, the medications or the equipment we’re being prescribed.

Some of the practices that have become all too common in the healthcare industry have not yet been seriously addressed by legislators. Take upcoding, for example, when providers are encouraged to assign inaccurate or additional codes for procedures in order to trigger a higher reimbursement from public agencies such as Medicare.

Although federal agencies rely on judgments of medical necessity before they release funds, such decisions are often subjective. There is an opportunity for overutilization, when doctors are incentivized to prescribe or charge more for services and equipment because they know public or private insurance is picking up the tab.

Similarly, doctors sometimes recommend tests or treatments not so much for a patient’s benefit but to protect themselves from potential lawsuits. They’re practicing defensive medicine.

Click-and-close is a term used at Cigna to describe how the company encourages staff physicians to review first-stage or questionable denials as quickly as possible. A recent article in ProPublica reports that more thorough evaluations require researching guidelines, reading medical studies and scrutinizing medical records. Click-and-close reviewing means more money stays with the insurance company and often keeps patients from getting the vital but more complicated services they might need.

Direct-to-consumer advertising is meant to encourage patients to ask their doctors for specific drugs, tests or equipment. That practice frequently puts the doctor in the position of having to explain why these may not be in the patient’s best interest.

Pharmacy benefit managers run every aspect of the delivery of prescription drugs, from formularies, to prior authorizations and co-pays, to rebates. They’re the hidden middlemen between the insurance companies and the pharmacies, profiting at almost every stage in the supply chain.

And, of course, there’s nothing new about kickbacks, the rewards given to medical professionals for prescribing specific procedures, equipment or drugs. Free vacations, cash, speaking positions and research grants are some of the many kinds of gifts that can call into question the value of what you’re being prescribed.

It’s hard enough to choose the best medical insurance for our families, but the task is much more difficult when none of us are in a position to know how much pressure is being put on medical professionals for corporate or personal financial gain.

Julie Woodward is a retired teacher who collaborates with other volunteers, the Westchester Library System and Westchester County’s Department of Senior Programs and Services to provide counseling on Medicare. Audio chapters of her comprehensive workshop and upcoming events are available at https://seniors.westchesterlibraries.org/demystifyingmedicare/.

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