Medicare disadvantage!

[bedrock]

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Members don't see this ad.

Not only are medicare advantage plans terrible for patients and physicians, but they cost taxpayers 22% more !!!!

Taxpayers spend 22% more per patient to support Medicare Advantage – the private alternative to Medicare that promised to cost less

Rather than finding efficiencies and saving money all around, the private companies that administer the Medicare Advantage option to Medicare are profiting at seniors’ – and taxpayers’ – expense.

theconversation.com

 

[Laryngospasm]

In other news water is wet at 10 bob!

 

[BoardingDoc]

Not only are medicare advantage plans terrible for patients and physicians, but they cost taxpayers 22% more !!!!

Taxpayers spend 22% more per patient to support Medicare Advantage – the private alternative to Medicare that promised to cost less

Rather than finding efficiencies and saving money all around, the private companies that administer the Medicare Advantage option to Medicare are profiting at seniors’ – and taxpayers’ – expense.

theconversation.com

Maybe someone should let Dr. Oz know.

Spoiler alert: he doesn't care. I worked in his lab many years ago. At that time his medical knowledge and skill was already so poor that he wasn't allowed to do any cases without another CT surgeon present. I'm sure he's going to tell us how MA plans are the bees knees and should be a nationwide standard.

Definitely anxious about his new job.

 

[hyperalgesia]

Not only are medicare advantage plans terrible for patients and physicians, but they cost taxpayers 22% more !!!!

Taxpayers spend 22% more per patient to support Medicare Advantage – the private alternative to Medicare that promised to cost less

Rather than finding efficiencies and saving money all around, the private companies that administer the Medicare Advantage option to Medicare are profiting at seniors’ – and taxpayers’ – expense.

theconversation.com

That 22% is worth it for politicians to deflect blame for denial of care. Sucks for everyone else though.

 

[NMOI]

I actually printed out a bunch of copies of this news article below. I have a big stack of them with a sign that says "Important Medicare Information" I think it helps minimize the number of my patients who switch to these inferior plans.

Older Americans say they feel trapped in Medicare Advantage plans

 

[Baron Samedi]

Hm who would have guessed privatization of a basic human need wouldn't work out so great?

I'm sure it'll be different for our schools and prisons.

 

[sloh]

Maybe someone should let Dr. Oz know.

Spoiler alert: he doesn't care. I worked in his lab many years ago. At that time his medical knowledge and skill was already so poor that he wasn't allowed to do any cases without another CT surgeon present. I'm sure he's going to tell us how MA plans are the bees knees and should be a nationwide standard.

Definitely anxious about his new job.

Also…

Dr. Mehmet Oz, nominated to lead the Centers for Medicare and Medicaid Services (CMS), has financial interests that could present conflicts regarding Medicare Advantage. Financial disclosures from his 2022 Senate campaign reveal that he and his wife owned up to $550,000 in UnitedHealth Group stock and up to $50,000 in CVS Health stock. Both companies are major providers of Medicare Advantage plans. 

Additionally, Dr. Oz has publicly advocated for expanding Medicare Advantage. In a 2020 Forbes article, he proposed a “Medicare Advantage for All” system funded by a 20% payroll tax.  This dual role as a proponent of Medicare Advantage and an investor in companies benefiting from its expansion raises concerns about potential conflicts of interest.

If confirmed as CMS administrator, Dr. Oz would oversee programs like Medicare Advantage. His financial ties to companies in this sector could influence policy decisions, highlighting the importance of transparency and appropriate measures to address any conflicts.

God bless ChatGPT.

 

[SSdoc33]

Since when do conflicts of interest matter in a trump administration? His cabinet picks won’t even have to be betted by the fbi. No security clearances. Doesn’t matter anymore

 

[Ducttape]

Not only are medicare advantage plans terrible for patients and physicians, but they cost taxpayers 22% more !!!!

Taxpayers spend 22% more per patient to support Medicare Advantage – the private alternative to Medicare that promised to cost less

Rather than finding efficiencies and saving money all around, the private companies that administer the Medicare Advantage option to Medicare are profiting at seniors’ – and taxpayers’ – expense.

theconversation.com

so i take this to imply that you think that Medicare Advantage programs should not be under the auspice of private insurance and should all be universal government run...

 

[pastafan]

I've never liked Oz but now he has really surprised me:

Opinion: Medicare Advantage crisis deepens as Dr. Oz launches ‘aggressive’ audits - MarketWatch 5/25/25, 7:29 AM

https://www.marketwatch.com/story/m...ches-aggressive-audits-3485aaa9?mod=home_lead Page 1 of 5

 

[pastafan]

https://www.wsj.com/politics/policy/lawmakers-seek-to-close-va-loophole-that-funnels-billions-to-private-medicare-insurers-cfbe0b19?st=BCsNje&reflink=desktopwebshare_permalink

 

[Ducttape]

this is the type of waste that needs to be rooted out.

3rd party middle men - insurance companies, pharmacies and pharmacy benefit managers.

 

[drusso]

this is the type of waste that needs to be rooted out.

3rd party middle men - insurance companies, pharmacies and pharmacy benefit managers.

Don't forget tax-evading "non-profit" hospitals...

Opportunities for Medicare Site Neutrality in 2025

The end of the election season means Congress’s lame duck session begins and members know they have one last chance to finish their priorities

paragoninstitute.org

 

[Agast]

This year the prior auth for medications has been expiring every 3 months for some companies, instead of 12. It’s a lot of unnecessary paperwork for us and delay for the patients.

 

[soccrwz]

on the PA front, announced today

https://www.npr.org/sections/shots-health-news/2025/06/24/nx-s1-5442713/rfk-jr-dr-oz-health-insurance-prior-authorization

 

[callmeanesthesia]

I’ll believe it when I see it.

 

[hyperalgesia]

I’ll believe it when I see it.

It will always be wackamole with a population healthcare system like ours.

If insurers facilitate PAs, they'll raise premiums.

PAs exploded when Obamacare mandated other things.

Remember when Obama and Chuck Schumer said, "Finally, we're in the driver's seat!"

 

[PinchandBurn]

on the PA front, announced today

https://www.npr.org/sections/shots-health-news/2025/06/24/nx-s1-5442713/rfk-jr-dr-oz-health-insurance-prior-authorization

Concern i have is currently if aomething is prior auth required atleast theres a lcd etc we have to follow.

Also we have some recourse as it was authorized.

I wish this would go further. Meaning not taking the money back. Lets face it thats more important. Not requiring a prior auth but then clawing back the money would be scarier...

 

[clubdeac]

This year the prior auth for medications has been expiring every 3 months for some companies, instead of 12. It’s a lot of unnecessary paperwork for us and delay for the patients

What meds are you having to get Prior authorization for?

 

[soccrwz]

We have PAs for generic meds like tramadol, lidocaine patches, butrans etc. Some plans just PA anything but the cheapest meds

 

[Agast]

What meds are you having to get Prior authorization for?

Belbuca, buprenorphine patches
Xtampza
Metaxalone
Tramadol ER
Nucynta

 

[cowboydoc]

What meds are you having to get Prior authorization for?

Got one for pregabalin today. Nope, go to goodrx.

 

[SSdoc33]

stop writing prescriptions

makes things much easier

 

[bedrock]

stop writing prescriptions

makes things much easier

LOL,
So you just offer pokes and nothing else? No gabapentin, tramadol , or basic muscle relaxant?

 

[BoardingDoc]

LOL,
So you just offer pokes and nothing else? No gabapentin, tramadol , or basic muscle relaxant?

I can't speak for SSDoc, but I suspect the answer is that you're correct. The group I'm joining in a month does no chronic prescribing. I'll write for a couple of days of Norco if I implant a SCS or something else where I expect reasonable post-op pain. Other than that, nope.

Even the meds you wrote above as seemingly minor, nothing issue meds, have issues. I frequently write for all of those now in fellowship.

Tramadol is still an opioid, so I'm not putting anyone on that long term as I hate COT as I've mentioned elsewhere.

Gabapentin and muscle relaxants I have gotten at least 1 or 2 PA requests or denials per day for the past several weeks. Either tizanidine or cyclobenzaprine won't be on formulary for the patient's random insurance and I'll have to change it. Then the patient sees the Rx is different and they call to complain...blah blah blah... waste of time.

Gabapentin is getting rejected from some random insurances around me if I'm writing it for off label uses which, spoiler alert, is 90+% of the way gabapentin is written. Such a pain.

Putting down the Rx pad is going to save me close to an hour a day.

 

[SSdoc33]

LOL,
So you just offer pokes and nothing else? No gabapentin, tramadol , or basic muscle relaxant?

injections, appropriate referrals, PT, EMGs, exercise and PT advice, bracing.

let the referring PA or NP mess around with gabapentin. not exactly practicing at the top of your license

 

[Dr. Ice]

I agree with mostly non or limited prescribing but I do feel like it would be cruel to not offer something for a hot radic and point the finger at insurance with PT nonsense or turf back to primary. Gabapentin, medrol, muscle relaxer is ok sometimes. I always tell them I will try not that I will prescribe and then I tell them the insurance may provide a challenge. I feel like sometimes, we have to put forth a full effort even though it might require a PA.

 

[Taus]

I agree with mostly non or limited prescribing but I do feel like it would be cruel to not offer something for a hot radic and point the finger at insurance with PT nonsense or turf back to primary. Gabapentin, medrol, muscle relaxer is ok sometimes. I always tell them I will try not that I will prescribe and then I tell them the insurance may provide a challenge. I feel like sometimes, we have to put forth a full effort even though it might require a PA.

Agreed. I can’t see not prescribing at all. Compression fracture, hot radic etc.. not talking chronic opioids or prescribing anything indefinitely,, but the basic stuff.

 

[SSdoc33]

ill write for oral steroids very rarely. usually, i just get them in for an epidural quickly.

call me cruel if you want. but the PCP can write just as well as i can, and i have a 3 month waiting list. so.......

 

[DOctorJay]

ill write for oral steroids very rarely. usually, i just get them in for an epidural quickly.

call me cruel if you want. but the PCP can write just as well as i can, and i have a 3 month waiting list. so.......

does your institution also have a "traditional pain management" group? are you interventional within an ortho department?

 

[SSdoc33]

does your institution also have a "traditional pain management" group? are you interventional within an ortho department?

yes and no. nobody Rx chronic opioids. i mainly work in an ortho dept but there is an anesthesia-based group as well. i generally believe that oral meds arent really a good option, and doing all the clicks for the medications and phone calls and refills and pre-auths and follow ups just isnt worth my time anymore. i can let somebody else titrate the gabapentin, or prescribe muscle relaxers or NSAIDs.

 

[DOctorJay]

yes and no. nobody Rx chronic opioids. i mainly work in an ortho dept but there is an anesthesia-based group as well. i generally believe that oral meds arent really a good option, and doing all the clicks for the medications and phone calls and refills and pre-auths and follow ups just isnt worth my time anymore. i can let somebody else titrate the gabapentin, or prescribe muscle relaxers or NSAIDs.

it's not an insignificant frustration. I routinely receive refill requests for meds because my staff can't figure out that the patient needs to be seen prior to the medication running out. very little opioids in my practice as well. and then the calls regarding the medication isn't working or can we switch to something else.

a few years ago we were able to curtail the opioid prescribing frenzy by taking over pain patients immediately from the PCPs and now they're in the habit of doing nothing for pain. best I can do in my situation is try and turf all this stuff to my PA.

 

[SSdoc33]

it's not an insignificant frustration. I routinely receive refill requests for meds because my staff can't figure out that the patient needs to be seen prior to the medication running out. very little opioids in my practice as well. and then the calls regarding the medication isn't working or can we switch to something else.

a few years ago we were able to curtail the opioid prescribing frenzy by taking over pain patients immediately from the PCPs and now they're in the habit of doing nothing for pain. best I can do in my situation is try and turf all this stuff to my PA.

i didnt start off not prescribing medications. it just sort of developed organically. i guess im lucky in that i have such a large referral base that it doesnt matter

 

[clubdeac]

injections, appropriate referrals, PT, EMGs, exercise and PT advice, bracing.

let the referring PA or NP mess around with gabapentin. not exactly practicing at the top of your license

I hate that term "practicing at the top of your license"

People use it to do whatever they want. There's a guy in our practice that does injections all day every day and has his PAs do all of his clinic. He says being in clinic doesn't allow him to "practice at the top of his license". What a bunch of bs. Soon he'll be replaced by NP/PAs doing injections and he'll have nothing else do with his license. Honestly though, the closer I get to seeing the light at the end of the tunnel, the less I care. Docs have screwed themselves in this regard

 

[GorillaPanic]

I manage a lot of medications (including a fair amount of opioids from my sizeable number of cancer patients), and I spend maybe 3 mins a day doing anything related to scripts… your support staff should be handling most of the issues around meds. They chart check, pend, and then forward to me to sign. Or the patient sends a request virtually and I click one button to sign. If there’s a PA issue, our MA will submit it and I never know about it.

 

[cowboydoc]

I manage a lot of medications (including a fair amount of opioids from my sizeable number of cancer patients), and I spend maybe 3 mins a day doing anything related to scripts… your support staff should be handling most of the issues around meds. They chart check, pend, and then forward to me to sign. Or the patient sends a request virtually and I click one button to sign. If there’s a PA issue, our MA will submit it and I never know about it.

Do you have a sense of how much time your staff spends doing this? I was shocked when I took a deeper dive. They chase BS all day in my clinic. PAs for $10 drugs, etc. ~80 calls/day.

I’m not going to stop prescribing, but I’m getting a lot more stingy with rxs so my staff can devote more time to better pursuits.

 

[Agast]

I had chat gpt draft a response letter to an insurance denial explaining why their suggestions of a fentanyl patch or methadone was dumb and dangerous. It worked!

 

[bedrock]

I agree with mostly non or limited prescribing but I do feel like it would be cruel to not offer something for a hot radic and point the finger at insurance with PT nonsense or turf back to primary. Gabapentin, medrol, muscle relaxer is ok sometimes. I always tell them I will try not that I will prescribe and then I tell them the insurance may provide a challenge. I feel like sometimes, we have to put forth a full effort even though it might require a PA.

injections, appropriate referrals, PT, EMGs, exercise and PT advice, bracing.

let the referring PA or NP mess around with gabapentin. not exactly practicing at the top of your license

Agreed. I can’t see not prescribing at all. Compression fracture, hot radic etc.. not talking chronic opioids or prescribing anything indefinitely,, but the basic stuff.

Agree. It is cruel not to provide some simple non opioid short term meds. The key being .....short term. I tell every patient that "I'm writing this script to help you get through this current pain episode, if you need this medication chronically for the rest of your life, then your PCP will need to write it". I always make sure that final point is understood.

Its easy to stay away from prior auths. Don't prescribe anything complicated. And you don't need to titrate, just write the script so the patient titrates it themselves.

For example, for a hot radic with impaired sleep (in a non obese patient), I will write gabapentin 100mgs 1-2 caps PO QAM PRN, and 2-4 caps PO QHS PRN, #180, no refills. If patient has hot radic + significant spasm, I will add tizanidine 2mg 1-2 tabs q6 PRN, #180. no refills, or Robaxin QID PRN.

If non elderly and struggling to sleep while waiting for procedure, then Flexeril 10mg, 1/2 to 1 tab PO QHS PRN, #30, no refills

If non elderly patient hasn't done conservative care, and their insurance is a stickler for conservative care, but the patient isnt sleeping or functioning well, then Mobic/celebrex 1-2x daily, (#30-60), and flexeril 10mg 1/2 to 1 tab PO QHS PRN, #30. You help the patient, the patient can sleep which is very important for healing, and writing for a safer NSAID provides some pain relief and helps the patient get authed for MRI or procedure at follow up visit.

Those are not hard or require much time and almost never require a PA. In past, patients on a particular crap insurance had issues with tizanidine, but we not longer take that insurance.

Easy and quick to write patient a one time script for gaba, flexeril, celebrex, mobic, and the occasional steroid burst, depending on the clinical situation.

 

[clubdeac]

Agree. It is cruel not to provide some simple non opioid short term meds. The key being .....short term. I tell every patient that "I'm writing this script to help you get through this current pain episode, if you need this medication chronically for the rest of your life, then your PCP will need to write it" I always make sure that final point is understood.

Its easy to stay away from prior auths. Don't prescribe anything complicated. And you don't need to titrate, just write the script so the patient titrates it themselves.

For example, for a hot radic with impaired sleep (in a non obese patient), I will write gabapentin 100mgs 1-2 caps PO QAM PRN, and 2-4 caps PO QHS PRN, #180, no refills. If patient has hot radic + significant spasm, I will add tizanidine 2mg 1-2 tabs q6 PRN, #180. no refills, or Robaxin QID PRN.

If non elderly and struggling to sleep while waiting for procedure, then Flexeril 10mg, 1/2 to 1 tab PO QHS PRN, #30, no refills

If non elderly patient hasn't done conservative care, and their insurance is a stickler for conservative care, but the patient isnt sleeping or functioning well, then Mobic/celebrex 1-2x daily, (#30-60), and flexeril 10mg 1/2 to 1 tab PO QHS PRN, #30. You help the patient, the patient can sleep which is very important for healing, and writing for a safer NSAID helps the patient get authed for MRI or procedure at follow up visit.

Those are not hard or require much time and almost never require a PA. In past, patients on crap insurance might have had an issue with tizanidine, but we not longer take that insurance.

Pretty easy to write patient a one time script for gaba, flexeril, celebrex, mobic, and the occasional steroid burst.

Do you actually think gabapentin works or has any evidence for hot radics? The evidence is quite the contrary

If you’re not going to waste time writing scripts then certainly stop wasting your time writing placebos

 

[bedrock]

Do you actually think gabapentin works or has any evidence for hot radics? The evidence is quite the contrary

If you’re not going to waste time writing scripts then certainly stop wasting your time writing placebos

Gabapentin definitely works for many patients with radiculopathy (if the patient can tolerate a high enough dose).

For some patients, 100-200mg in am isn’t enough for pain relief but those same patients will tell me how helpful it is take 400mg of gabapentin QHS while waiting for an epidural.

 

[22yis]

Wtf is a hot ridic? And how does it differ from a cold one? Serious question

 

[lobelsteve]

Wtf is a hot ridic? And how does it differ from a cold one? Serious question

acute vs chronic. Crying in office because of pain and not stressors.

 

[Ducttape]

gabapentin seens to work best for patients who have other aspects of pain that may benefit from a mild anxiolytic.

besides a month or so of NSAID, the occasional muscle relaxant (mostly for anxiolysis), i generally give patients information on neuromodulators and have them review info then talk to their PCP re prescribing said neuromodulators.

i would say i spend 5 minutes a day refilling scripts on legacy patients without WC and 10 times that amount of time refilling legacy patients with WC scripts.