Episode 281- Medicare Disadvantage: Nate Kaufman and Rich Helppie Pt. 2

Are you getting what you pay for with your Medicare plan? This eye-opening conversation between healthcare insiders Nathan Kaufman and Rich Helppie pulls back the curtain on what they provocatively call "Medicare Disadvantage" plans.

When something sounds too good to be true, it usually is. Medicare Advantage plans tempt seniors with zero premiums, dental coverage, vision benefits, and even gym memberships. But these apparent perks mask a troubling reality: significantly restricted healthcare options when serious illness strikes. Our experts explain how insurance companies profit from delaying and denying care while creating increasingly narrow provider networks that limit access to specialists and top medical centers.

The most alarming revelation? The trap many seniors find themselves in when they discover these limitations. Once enrolled in Medicare Advantage, leaving becomes nearly impossible if you develop a serious condition, as new supplemental plans can exclude pre-existing conditions. Meanwhile, those with Traditional Medicare maintain freedom to choose providers nationwide, including prestigious research hospitals like Mayo Clinic or MD Anderson, without administrative barriers or insurance company gatekeepers.

For anyone approaching Medicare eligibility or reconsidering their current coverage, this episode provides crucial guidance. Our experts recommend a clear path: Medicare Parts A, B, and D, plus a comprehensive Medigap policy. While this combination involves upfront premiums, it offers something priceless: control over your healthcare decisions precisely when you need it most.

Subscribe to Healthcare Bridge on your favorite podcast platforms or find us at the Common Bridge on Substack to continue exploring the vital connections shaping our healthcare landscape. Your health decisions matter—make them with complete information.

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Episode Transcript

Speaker 1 (00:00):
Welcome to this episode of the Healthcare Bridge
, where we explore the vitalconnections shaping our
healthcare landscape.
Hosted by Nathan Kaufman,managing Director of Kaufman
Strategic Advisors, theHealthcare Bridge is dedicated
to improving healthcare deliveryby strengthening the strategic
and financial performance ofhealthcare providers.
As part of the Common Bridgefamily, our focus is on
fostering insightful,nonpartisan conversations that

(00:23):
drive meaningful change in thehealthcare industry.
We invite you to join us as webuild bridges toward a healthier
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Speaker 2 (00:37):
This is Nate Kaufman with the Healthcare Bridge,
welcoming Rich Helpe, thefounder of Common Bridge.
We're here today to talk aboutMedicare.
It's known as MedicareAdvantage Rich, you have another
name for this thing.

Speaker 3 (00:49):
Yeah, I call it Medicare Disadvantage because if
you pick unwisely, medicareDisadvantage could kill you or
it might trap you inside and younever can get out.
Now, nate, you and I havetalked about this a lot.
Traditional Medicare Part Ait's free, it's automatic.
Part B that's for youroutpatient services, physicians.

(01:09):
That's paid for on a slidingscale.
It's an 80-20, usually pays 80%of covered charges.
With that you need a Medigapplan.
That's a private insurance.
And then, of course, medicarePart D, which I'm a big advocate
of.
Medicare Part D.
I think it's a well-designedplan.
Medicare Advantage plans here'sthe pitch.
You get little or no premium.

(01:29):
You get added benefits likevision, dental, hearing and
maybe transportation, a gymmembership and over-the-counter
drugs.
So doesn't it seem a little oddthat you could get so much more
health care for so much lessmoney?
Does that sound possible?
Like you know what they say ifa deal sounds too good to be

(01:50):
true, probably is.

Speaker 2 (01:52):
Well, actually there's another saying if you
think health care is expensive,wait till it's free.
I mean, the bottom line is thatif you look at Medicare
Advantage is that if you look atMedicare Advantage, the stocks
UnitedHealthcare have alldeclined materially, and the
reason they've declined is thatsooner or later, people get sick

(02:12):
.
And the issue with MedicareAdvantage is there's a number of
ways you I'll call themloopholes, not cheats that you
can find that will end upresulting in you getting paid
more.
One of them is representing howsick a patient is.
That actually increases theamount of money you get from the

(02:34):
government.
So the insurance companies takelots of their money and invest
in trying to make their patientslook as sick as possible to the
government so they get moremoney.
Well, those days are limitedbecause the government, after
decades, has figured that out.
Well, you take that loopholeaway and a few others, and now
you have a bunch of sick peoplethat you have to pay money to.

Speaker 3 (02:55):
So that's one way, that there's a way to manipulate
the system.
So we both have learned aboutpeople that said hey, what is
this?
I've got congestive heartfailure.
I never knew I had that,because some enterprising clerk
put that diagnosis into therecord.
So again, just the distinctionis Medicare advantage, medicare
disadvantage is that the insurergets paid a per member per

(03:20):
month fee, and by our government, by the tax dollars, and that
fee is set based on how ill thatperson is.
But guess what else that youbuy when you buy that medicare
premium?
You buy a gatekeeper, don't you?

Speaker 2 (03:37):
well, you, most of the time you buy a gatekeeper,
but more and more the gatekeeperis the insurance company, and
so the gatekeeper concept wasyou had to go to a primary care
physician, get a referral inorder to see a specialist.
That was kind of a good ideabecause the gatekeepers were
doctors.
Now what happens is when youneed to go to a specialist or

(03:59):
get a procedure, thatinformation is transmitted back
to Minnesota or back to Indianaand some doctors AI system
determines whether it'snecessary or not, and then a
physician spends like a fewseconds reviewing that to see if
he or she confirms and as aresult, there's huge delays and

(04:21):
denials in the system, and forevery delay and denial of care,
the insurance company actuallymakes more money because of the
conflict of interest associatedwith I got my premium.
If I don't have to provide forcare, my shareholders make more
money.

Speaker 3 (04:38):
Now contrast that with traditional Medicare.
So let's just take this example, a generic example a Medicare
patient on traditional Medicareis referred to a specialist at a
research hospital you know,memorial Sloan, kettering, mayo
Clinic, md Anderson, of coursethe University of Michigan and

(04:59):
they have their traditionalMedicare and the physician at
that research hospital iswilling to see them.
What's the difference in theprocess versus somebody, that's
say, coming from Southern Ohiowith a Medicare Advantage plan
trying to go to one of thosespecialty research hospitals?

Speaker 2 (05:17):
Well, what happens is you have to be, you go to
what's known as an in-networkprovider.
Let's talk about anotherloophole.
You have to have an adequatenetwork for your population and
the problem basically, is thatwho's measuring adequacy?
So they've done some studieswhere they see that insurance
companies are creating ghostnetworks, that is, they list a
number of providers thatactually aren't available to

(05:40):
provide care.
That's first and foremost.
The second thing is you can'tgo where you want If you have
cancer.
You can't just say, hey, I livein Oklahoma, I want to go to
Johns Hopkins, which you canunder traditional Medicare.
You essentially have to go innetwork, which means choosing
somebody locally.
And what's happening?
Because of the delays anddenials and the underpayments

(06:04):
coming from the MedicareAdvantage plans, many, many of
the really good doctors andhospitals are dropping out of
Medicare Advantage.
Of the really good doctors andhospitals are dropping out of
Medicare Advantage.
And keep in mind, once you'rein Medicare Advantage for a year
, if you leave, yoursupplemental plan is no longer
based on the community, it'sbased on your own personal

(06:27):
health care.
So if you leave because, say,you've got I don't know
pancreatic cancer, yoursupplemental plan is going to
say we're covering this person,except for pancreatic cancer.
So for that reason, because I'mon Medicare, I see no good
reason at all to let afor-profit insurance company set

(06:50):
my network, tell me where to go, tell me which care I can have,
et cetera, and so I justencourage everybody to stay out
of it.

Speaker 3 (06:59):
The term of art that those of us on the inside know.
It's called a narrow network,and the way that the insurance
provider can dictate price is totell the health systems that
you want to go that they're notin network.
So they're saying we won't sendyou our patients if you don't
meet our price point.

(07:19):
And so therefore, while youmight want to go to Johns
Hopkins, you've got to go to ABCHospital, which may have
substandard care compared toJohns Hopkins probably would
with specialties like thatversus if you have traditional
Medicare and you have adiagnosis and a provider is

(07:41):
willing to see you.
That's all there is to it.
The doctor makes the decision,the patient makes the decision.
Now, of course, medicare hasits rules, but you've already
got the diagnosis in hand andmost doctors, most hospitals
accept Medicare, and once youaccept one, you've got to accept
all Medicare patients, soyou're going to have much more

(08:03):
choice with traditional Medicare.

Speaker 2 (08:06):
Yeah, I mean I can't emphasize enough how important
it is to select your providersproperly.
I just had a colleague recentlywho had this strange illness
just pop up.
The ambulance took her to thelocal community hospital and
they basically said we bettership her to University of
California San Francisco rightaway or she's not going to make

(08:28):
it.
And the fact is that that isnot an inexpensive hospital to
be transferred to.
But had they not done that, sheprobably wouldn't have survived
.
So again, we want people whoare informed to make decisions
about our healthcare, not AI andremote physicians that really
have no experience with aparticular patient physicians

(08:51):
that really have no experiencewith a particular patient.

Speaker 3 (08:56):
So I think we've landed in the same place.
Nate Medicare Advantage, whileit looks like it's such a good
deal, you're buying a narrowernetwork.
You're buying a gatekeeper thatcan deny you care and you're
dealing with someone whoseincentive is to delay your care.
Now, that's not to say thatthere aren't good plans out
there.
Some people are very satisfiedwith them.
But guess what?
Next year your network canchange.

(09:19):
So you know, if you like yourdoctor, maybe you'll keep them,
maybe you won't.
Indeed, that happened here inMichigan with us.
We got a notification that theywere having difficulty getting
the Humana Medicare Advantagepatients eligible because they
were having negotiation issueswith Humana.
We're not in that plan, but ourdoctor said if you're in that

(09:40):
plan you need to be alert.
And again, that is not theHumana prescription drug plan,
which works really well, but theMedicare Advantage plan part of
it.
So again, if you're put off bythe premiums that you might have
to pay under traditionalMedicare, I remember you're
going to get what you pay for,which is a very broad network
and your ability to control yourown destiny, much better than

(10:01):
these Medicare Disadvantageplans.

Speaker 2 (10:04):
I absolutely agree, and you essentially get what you
pay for, and, at the end of theday, when you're sick, you want
those options that you don'thave if you're locked into a
Medicare Advantage plan andagain, medicare Advantage is a
great idea that's gone bad.
And so, while there are peopleout there that are reasonably

(10:25):
happy with their plan, theconcern is, if you get sick, you
need options, and you can'thave options with Medicare
Advantage.
Anything else, rich, that youwant to mention.

Speaker 3 (10:35):
Those people that are listening that are coming up to
Medicare age.
Four parts Medicare A you getthat automatically.
Medicare Part B definitely signup for that.
You'll need a Medigap plan tocover what A and B don't cover
and that, depending on whatmarket you're in, you're going
to it'll be a Blue Cross or aUnited or you know whomever and
then Medicare Part D andMedicare Part D very important

(10:58):
to sign up for that when youbecome eligible, because even if
you're not taking anyprescription drugs, try to opt
out.
There's a big catch-up premiumif you try to come back in later
.
So Medicare Part D is a verywell designed plan.
In a perfect world I'd makeeverybody eligible for Medicare
Part D, but that's probably asubject for another day.

Speaker 2 (11:18):
There's a lot of nuances in healthcare and that's
why it's important to ask aninsider.
And that's what we are, andthis is Nate Kaufman with Rich
Helpy with the Healthcare Bridge, signing off.
Thank you for joining with RichHelpy with the Healthcare.

Speaker 1 (11:30):
Bridge signing off.
Thank you for joining us onthis episode of the Healthcare
Bridge.
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financial analysis can transformhealthcare delivery.
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(11:52):
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