Medicare Advantage: Last Week Tonight with John Oliver (HBO)

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Our main story tonight concerns health care. Ostensibly, the subject matter of The Pits, which is slightly about health care, but much more about the gentle head tilt of Noah Wiley. On behalf of several members of my staff, engulf me in that hoodie, you casual Friday hero.

Specifically, we're gonna talk about Medicare, the federal program for those 65 or older or with qualifying disabilities. Now, open enrollment for it began on October 15th and will run through December 7th. And it's why this time of year sees tons of ads like these.

Hi, I'm Joe Namath.

If you're on Medicare, this is important information.

I, William Shatner, here with a new message

about Medicare benefits.

Hi, I'm Jimmy J.J. Walker. If you're on Medicare, listen to this.

I'm Meredith Vieira. What's complicated and confusing

that many people over 65 deal with each year?

Medicare.

Okay, this isn't the point, but the question, what's complicated and confusing that people over 65 deal with each year, is just too broad, given that the answer is, everything, everything confuses them. aired on TV. That's over 8,000 a day.

Picture what a mountain chicken looks like in your head right now. Do you have it?

-...which is just wrong. -"Mountain chicken"?

Sounds like, at minimum, a chicken that lives in the mountains.

It's mountain chicken. It's definitely not Jeff.

a percentage expected to grow to nearly two-thirds by 2034, which is concerning, because these plans can have real issues. One expert has said, the best candidate for Medicare Advantage is someone who's healthy.

We see trouble when someone gets sick. But that is a problem, because statistically, most people will get sick. It's just a fact of life. Like, all hamsters die. Most cats hate you, and if Jeremy Alan White is on screen, he is sweating.

-♪ Sweating ♪ -Acting is sweating. We all know that. And that's by no means the only flaw here, because as you will see, while these plans can be great for companies' bottom lines, they can be woefully insufficient for those who signed up for them and the providers who have to deal with them. Medicare Advantage basically has all the problems

of private insurance, but applies to a more vulnerable population. So given that, tonight, let's talk about Medicare Advantage. What it is, what the coverage can be like, and whether you or someone you know should sign up. And to understand it, you first need to understand how Medicare works, which already isn't easy, because as you'll know, if you've ever enrolled in it yourself

or had to help someone else do it, it is fucking confusing. On a scale of one to inception, it is basically a tenet, and I don't say that lightly. To put it very simply, Medicare currently has four components, Part A, B, C, and D.

Part A covers hospital and other inpatient care. That's what you've paid into your whole life. And for most, you can enroll at 65 with no additional premium due. Part B covers doctors visits and outpatient services. Now, you do have to pay a monthly premium for that.

That's typically taken out of your Social Security check. And even then, it only covers 80% of your cost. So the remaining 20%, you have to pay for out of pocket. But you can buy a separate Medigap plan to cover that, which typically costs $200 or more a month. And that gap is something ads pushing Medicare Advantage

like to highlight, like this one featuring Kelsey Grammer. Doesn't look good. He's missing 20%. He should've got better insurance. Fingers crossed. Are you missing 20% too? That's what your Medicare insurance might not pay for. That 20% is critical to your health care and your wallet. See, original Medicare only covers about 80% of your Part B medical costs. The rest is up to you.

Can be thousands of dollars, right? Me at least expect it. So let Coverants help find a Medicare insurance plan that doesn't leave you so...

exposed.

Stop it! You stop it right now, Frazier! Though to be fair, that is not the creepiest thing he's ever said about the medical profession, given his memoir features the quote, "'Nice girls made me really nervous, claustrophobic. But broken women, women in pain, women looking to be fixed, are for these women the doctor was in.

That is on the back cover, and it is wild to publish a book where you essentially argue, if you fuck me, you might need professional help. Anyway, that is part B. Now, if you want prescription drugs, and if you're a senior citizen, you definitely do,

you need to pay for a separate Part D premium, which helps cover those. And that leaves us with Part C, which is Medicare Advantage. It functions as an alternative to all the other parts in that it helps cover hospitals, doctor visits, and usually drugs, while offering, uh,

often extra benefits, uh, like some dental, vision, and hearing coverage, or even debit cards to help pay grocery bills. And it does all of that for a relatively low upfront cost, as other than that standard premium taken out of your Social Security check, over three quarters of enrollees pay no additional premium at all.

So it is pretty appealing on the surface. And what I don't have to show you, one more ad for it, especially as it basically recaps everything I just said, I'm gonna do it anyway, because it is magnificent.

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Al, did you make that call?

Honey, we already have Medicare. Why do I need to call?

Alan, the Feldman said we may be able to get additional benefits with a Medicare Advantage plan right here in our zip code with zero-dollar monthly premiums.

Honey, what do you mean, additional benefits?

We turned 65, we got Medicare. That's all there is to it, right?

I'm talking about Medicare Part C, commonly called Medicare Advantage. We have traditional Medicare, which is only Medicare Parts A and B, but not Part C. Wait. So not everyone on Medicare has a Part C plan? No, that's why we need to call, because there may be plans available with additional benefits that aren't covered under Medicare Parts A and B. We don't have a Medicare Part C plan

which covers everything in Part A and Part B, plus extra benefits in Medicare Part C.

What kind of extra benefits?

There are great plans that may be available with extra benefits like dental, vision, and hearing.

Did you say dental?

That is, and this is true, only the first half of that commercial. It has it all. Amateur porn-level acting, wild physical gestures, the totally unnecessary undercurrent of a broken marriage, and the phrase,

right here in our zip code. It is... perfect. I also love the disclaimer saying, -"Paid actor portrayal." -$1,000. As if we'd be so sucked in by the natural delivery of concussed Rob Reiner and over-caffeinated Amy Sedaris here that we might need to be reminded.

But the thing is, there are a lot of drawbacks to Medicare Advantage plans. For a start, they come at an inflated cost to taxpayers, which is a bit weird, given that a big part of the argument for creating this system over two decades ago was that bringing in private insurers would help control cost. In fact,

here is Orrin Hatch back then, one of its biggest cheerleaders, making his pitch.

Choice. The right to pick the coverage you want. That's what Medicare Advantage actually gives you. Now, there are those who believe that socialism is the answer to everything. Let government do it. Government can do it more efficiently.

Well, if you believe that, you haven't watched the last 50 years.

Yeah, the whole argument was that it would expand choice, and companies would do a better job at controlling costs than the government. And look, some things are better when the private sector's involved. Take novelty slippers. Only through competition in the free market,

you get innovations like hairy feet slippers, creepy Marge Simpson slippers, Sigmund Freud slippers, Danny DeFito slippers, and golden penis slippers. And if you're wondering who the fuck would buy those, you are looking at him right here. Now, why did I buy these? I don't know. Probably because of something deep-rooted in my psyche,

stemming from my childhood, at least according to my Sigmund Freud slipper right here. But, sadly... Sadly, the private sector hasn't done as well with Medicare as it has with slippers, because these plans have never saved the government money.

In fact, a report last year estimated Medicare Advantage would cost the government over the previous 18 years an extra 591 billion. And this is partly down to the fact the major companies involved need to make profits for their investors, and they have found ways to do that.

One concerns how they get paid. Because in traditional Medicare, a provider treats you, and the government pays a fee for it. But in Medicare Advantage, plans get a fixed payment from the government for each member they take on, regardless of whether you get treatment or not.

And crucially, that payment's based in large part on what illnesses you're listed as having, because insurers are entitled to extra money when their patients are diagnosed with conditions that are costly to treat. Here's a report from several years ago

explaining how it basically works.

The insurance company uses what are known as diagnosis codes to report that person's level of sickness

to the government.

Well, they pay one rate for plain old diabetes,

and then they pay another rate for diabetes with complications. If you write down in the file that the patient has diabetes for plain old diabetes. And then they pay another rate for diabetes with complications. and has complications with eyesight,

or other things, they'll get paid a higher rate. Unfortunately, a lot of things that sound good, or in my case, for them to look at me, down at the chart, look at me again, back at the chart, and then say, -"48 years old?" -$48?

-$48? -$48?

Are we sure about that? And while insurers will claim they're just being thorough, they've been repeatedly accused of essentially pulling a Munchausen by paperwork. In 2022, the Times found eight of the ten biggest Medicare Advantage insurers had submitted inflated bills

according to federal audits, and that four of the five largest players had faced federal lawsuits, alleging their efforts to over-diagnose their customers had crossed the line into fraud. And some have been accused of getting very sneaky

to add patient codes. For instance, many tout home visits with ads featuring happy seniors excitedly greeting health care workers at their door. Here's how United Healthcare advertises theirs.

Remember the good old days when doctors made house calls? United Healthcare offers their Medicare Advantage members an annual visit from a licensed clinician in their own home at no extra cost. Home visits may include a review of your medical history, a check of your vital signs, and a chance to talk

about your health concerns. With house calls, being healthy starts at home.

Yeah, and you can see how attractive that is. Not least because the senior gets a visitor. And you know how happy that makes them. The elderly love exactly three things. Having guests, talking to guests, and then freaking out when that guest

sits in their fucking chair! But an investigation found that in programs like that one, companies push nurses to run screening tests and add unusual diagnoses, turning the roughly hour-long stops in patients' homes into an extra $1,800 per visit on average. And while United will insist most of the conditions

it's coded for in its House Calls program haven't raised payments, some very much have. For instance, documents show its software would suggest the diagnosis of secondary hyperaldosteronism, a condition in which levels of the hormone aldosterone rise without requiring it be confirmed by a lab test.

UnitedHealthcare apparently diagnosed that nearly a quarter million times after home visits, leading to $450 million in government payments over just three years. Even though a former house calls nurse said, in a million years, I wouldn't have come up with a diagnosis

of secondary hyperaldosteronism. And of course not. I didn't even know what hyperaldosteronism was before working on this piece. And to be honest, I still don't really know much about it. Aside from the fact that you can rearrange the letters

to spell modernist horseplay, which... isn't nothing, but it does feel close to it. Now, I have to tell you, UnitedHealthcare claims that report misrepresents house calls, which is just about supplementing doctor's visits and identifying gaps in patient care.

I presume they're currently making that same argument to the DOJ's criminal health care fraud unit, which is investigating its Medicare billing practices. And I wish them the very best of luck with that. But they are not the only company who face these sorts of accusations. An insurer called Independent Health

faced similar claims, including that a woman in one of their Advantage plans was apparently coded for prostate cancer. Because, according to an internal email, when a married couple has any disease, both were assigned to that disease, which is both ridiculous and also kind of romantic.

Do you, Tracy, promise to take Doug's diseases from tip to taint as long as you both shall live? I do. I really do. Now, again, I have to tell you, Independent Health did not admit liability, but they did pay $98 million to settle that lawsuit.

You know, the exact kind of thing you do when you're not liable for something. So, at this point, I think it's pretty clear, these plans aren't a particularly good use of taxpayer money. But are they good for patients? Well, on the surface, cheaper premiums sounds appealing.

And if you're relatively healthy, these plans can seem like the more attractive option. Just listen to this woman explaining why she and her husband picked one.

We are very active. I play pickleball twice a week. Um, we have a big garden, we have animals that we take care of, and so we're always doing something. And we wanted to retire while we were still able to do things together. Um, and that, we like the Advantage plan

because it seemed to fit our needs for that.

Right, and I get that that makes sense for her right now, because from the minute I saw that woman, I knew she played pickleball. She didn't need to tell me that. Everything about her screams, I'll dink your kitchen, then cross-court lob

until we bagel, because je suis la pickle bitch. And Medicare Advantage plans go out of their way to recruit people like her. Many even offer perks like gym memberships, which can be disproportionately attractive to relatively healthy beneficiaries. But, once you get sick, you can find out

your plan has a lot of limitations. For example, under regular Medicare, you can go to any doctor or hospital that takes it, which is most of them. But, with Medicare Advantage, as with most private insurance, you can typically only use doctors

in the plan's network and service area. And as those can change at any time, a doctor who is in network when you sign up can quickly fall out of it. And that can be a big problem. Consider this woman who had cancer

and who qualified for Medicare due to disability, but signed up for a Medicare Advantage plan thinking that it would save her money.

I went for my routine checkup. I'd been a Dana-Farber patient since 2013, and I got a bill. They're saying the provider's in that work, in the building, but the building of Dana-Farber is out of network, and I'm not allowed to go there anymore,

even though I'd been going there and had the same insurance. So, after all of these years, I have now moved my care to a different hospital because I can't go there anymore.

That is absurd. Her doctor was in network, but the building wasn't. It's one of those things that makes your brain hurt if you think about it for too long, like how gravity works, or why some people's bodies shit when they're scared, or how Bill Belichick's daughter was 17 years old the year his girlfriend was born.

Some things are just too difficult for you to comprehend. But it can be genuinely hard to find someone in network on an Advantage plan, and even if its list of providers looks good on paper, it can quickly collapse under the slightest inspection, as this man discovered.

I'm diabetic, so I looked under endocrinology. There were four listed, and the first two were at Schnucks grocery stores, and they weren't endocrinologists, they were just pharmacies. So, apparently, that means that they offer

two endocrinologists in this 25-mile radius, and that has me hugely concerned.

Is that enough for the senior population here?

No.

Yeah, of course it isn't. And finding out half your list is just grocery store pharmacies would be frustrating, because everybody knows you don't go there for an endocrinology appointment. You go there to check your blood pressure in the machine that makes your arm feel like

it's being squeezed by Paul Mescal's thighs. That is a thing that we all do. And that is not a one-off either. One review found the majority of Medicare Advantage organizations had between 30 to 60 percent inaccurate locations in their directories.

But even if you can find a provider, you may then have to deal with something called to get inaccurate locations in their directories. But even if you can find a provider, for the care your doctor says you qualify for, virtually all enrollees in Medicare Advantage

for some services. While these plans are supposed

as this doctor explains. We have to call for a prior authorization, We have to call an 800 number, some number, we have to give them all the data, we have to give them the insurance information, we have to give them the patient's date of birth, things like that, and then what they do is they give us, then, an authorization to fax them the information. So I've called them to get permission

to fax them a request, and then once they've got it, I've gotta call them while they discuss the fax. That's another barrier and obstacle to care that's incredibly time-consuming, has no value added, and it seems, uh, antithetical to trying to get prior authorization. What I really am getting is a prior authorization

to get a prior authorization.

Yeah, and everything about that sounds like a nightmare, including the presence of the words, -"Fax Machine." -$5,000. I thought we'd stopped making them around the same time that we stopped making good romantic comedies. In fact, I think the last time I saw a fax machine,

a frazzled Michelle Pfeiffer was getting horned up for George Clooney. Remember that? Remember good romantic comedies? The kind of films that feel like a blanket and make you leak from all your holes? What happened to this country?

Anyway, as you might guess, Medicare Advantage providers partly or fully deny millions of prior authorizations each year, and that can be maddening for those who need care. Take what happened to Gary Bent. He had significant complications from brain surgery, including being unable to stand or walk on his own.

His doctors said he needed a lengthy stay at a highly skilled rehab center. Now, under traditional Medicare, that would have been covered. But, he had a Medicare Advantage plan from UnitedHealthcare, which only approved him for a few weeks at a short-term rehab facility. And Gary's wife and daughter remember the advice

that they got from his care team about trying to appeal United's decisions.

They told me I would probably win one or two, maybe even three, but then the speed with which these denials came would increase. They would be fewer and fewer days apart, and eventually I was going to lose.

We felt like this process was designed to wear us out, and I would say it did wear us out.

Yeah, and that's exactly what happened. They won two appeals, then lost a third after an external reviewer sided with the company. While United Healthcare insists it was just following Medicare guidelines, Gary was sent home before his family felt he was ready,

with, by the way, a fever and neck pain, and within 11 hours of being discharged, he was rushed to the ER where he was diagnosed with meningitis. And that was just one step in a quick decline towards him dying the following winter.

A decline that his wife says was made worse by the added trauma of having to fight for the care he needed and was entitled to. And there are some things so awful, it's almost impressive to be able to make them worse. It's like seeing a Cybertruck with Diddy's face painted on it.

I don't know how you manage to do it, but I like this even less. And the thing is, delaying, underpaying, or denying care doesn't just hurt patients, it hurts hospitals too. Particularly those in rural areas, because they don't have the time or resources

to sink into constantly appealing decisions, which has had real consequences.

This was once the geriatric psychiatry unit at Alliance Healthcare in Holly Springs, Mississippi. Now, the hallway's hollow and bed's sitting empty. This operating room, only a few years ago, was doing five or six procedures a day. Now, zero.

Dr. Kenneth Williams is the CEO.

It died the last few years with Medicare Advantage.

to just check out the space.

I'll just switch back to regular Medicare.

You may not be able to.

are allowed to reject you based on them.

and getting rid of that 20% gap in coverage. But until then,

by a different name, and ideally,

Because as you've seen, they're just not the same.

but they do drastically different things.

it is this fucking guy.

starts with M.

A government entity dedicated to the health of seniors. Memed Az.

It's Medicare.

Memed Az, Fitz.

It's Medicare.

Well, guess what? I work for you now. Yep, they put me in charge of Medicare.

Now, how cool is that?

Not cool! Not cool at all! And it is just wild to see someone who's been on TV for two decades give the single worst line reading I've ever seen. And remember, we just watched these two go to town.

And one of the many reasons it's not cool is that Dr. Ross not only promoted Medicare Advantage in sponsored segments on his TV show, he once co-wrote an op-ed titled, Medicare Advantage for All Can Save Our Healthcare System, basically suggesting that we roll it out for everyone.

And while he's recently acknowledged some of the problems that I've mentioned, he's also said the administration wants to give insurers an opportunity to voluntarily fix them. Which I would say is the most ridiculous thing that he has ever said, except he did once do this.

So that's what you call a camel toe.

Yeah. He did once do this. So that's what you call a camel toe. Can I actually show you what camel toes look like?

Of course.

Here's a picture of what a real camel toe looks like.

Television was a bad idea. So, look, at the policy level, for now, we are kind of fucked. But in the meantime, if you or someone you know is considering one of these plans, first, if you can afford to buy a Medigap plan and enroll in traditional Medicare, you should do that. But if you can't, you should at least understand

the potential drawbacks of Medicare Advantage. And whatever you do, do not call those broker numbers on TV because they won't give you unbiased advice. They get much higher commissions if they funnel you to Advantage plans. So if you want independent advice,

you can call your state health insurance assistance programs. You can find your state's number at this website. And while I know it is basically impossible to escape these ads right now, we thought the least we could do is provide one for you that is technically accurate.

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Al, did you make the call?

What call?

The Feldman's said we may be able to get additional benefits with Medicare Advantage right here in our own zip code.

Our zip code?

Yeah, the zip code we live in. It covers the 8.6 square miles of our neighborhood.

Yeah, I know what a zip code is. But honey, we already have Medicare, so we don't need to call anyone.

Al, do you listen? I said Medicare Advantage. It has all the letters of the word Medicare, but none of the actual Medicare.

Wait a minute. It's not regular Medicare?

No.

That's why we need to call. The Feldman's said their Medicare Advantage plan has dirt cheap premiums.

Did you say dirt cheap?

Yes, Al, of course I did. What is wrong with you today? With Medicare Advantage, you get free gym memberships, a grocery allowance, and a nurse will come to our house.

For a threesome?

Oh, you'd love that, wouldn't you, Al? No, not for a threesome. The nurse will come to our house so that she or he can diagnose us with a bunch of diseases that we don't have and that our doctors don't even know anything about.

But what about conditions I actually have,

like my diabetes?

Not only will they cover it,

but I will suddenly have diabetes too.

Why?

Because it's romantic, Al.

Kiss me.

Hold on.

Do we at least get to keep our doctors?

Well, we get to choose from a list of doctors, but they're mostly just grocery stores, local middle schools, a JC Penney,

and an abandoned Chuck E. Cheese.

Did you say Chuck E. Cheese?

And if you find a doctor that's covered, well, you'd better hope that the building that he or she works in is too. Otherwise, you might be getting your prostate checked out in the parking lot and not in the fun way.

This is starting to sound like a bad idea.

No! No! It isn't! I want a Medicare Advantage Plan, Al. Plus, the premiums are so low. Just think of all the money we could save. Sure, the care might be worse, but that's okay because we're not sick right now in this very moment.

But what if we get sick later?

Well, then we're fucked, Al. But that's a later problem. Right now, we're active. You golf, and I play pickleball with Paul Feldman twice a week.

I didn't know you played pickleball with Paul Feldman.

Oh, yeah. I've been playing with Paul for years. He is great. In fact, I think I'm in love with him. Wait, did you did you say you're in love with him? Yes, Al. He fucks like a Toyota and loves like a Subaru. Now please, call the number and get us a doctor so that he can treat our herpes. Herpes?

Is that one of these fake diagnoses?

No, Al.

We both have herpes now.

Don't call this or any other number on your screen. Medicare Advantage is not traditional Medicare. It's administered by private insurance. Your doctor may or may not be covered. And if you or your wife is playing pickleball with Paul Feldman, seek medical attention immediately. Because you have herpes now.

Because you have herpes now. Paul Feldman gave you both herpes.