E15-mike-hughes
[00:00:00] Amy: I'll tell you when I was a house call provider, I once walked into a house and I was like, Oh, here's a quarter of a million dollars worth of durable medical equipment.
You know, there's like three bariatric, you know, beds and three bariatric wheelchairs and electric wheelchairs. It was like a DME graveyard of sorts. Like you just couldn't believe all of this. Stuff.  
Alex: Hello everybody. This is dr. Alex. Mohseni one of your co-hosts with mastering Medicare. And, we're really excited about today's. interview with a good friend of ours. and I'm going to let Amy introduce him. Go ahead, Amy. 
Amy: Okay. So, welcome everybody back to our, I don't like [00:01:00] 97th episode of mastering Medicare.
I'm just kidding. You know, what does it start like 15th episode. Oh my gosh. We're really cruising now. so I'm dr. Amy Schiffman, one of your cohosts and we are here today with one of my really good friends, Michael Hughes, who is a consultant. he has his own consulting company called Mitchell Lowey.
and he specializes in the intersection of aging technology and health. And I have worked with Mike on several projects over the years, and he's absolutely so brilliant as it comes to that intersection of aging technology and health, and also private duty, also known as home care. And today we're going to be talking about.
something that, we've talked about in prior podcasts, which has to do with private duty and we're going to actually have our very first episode where we kind of dive a little bit into, Medicare advantage. Like, I'm almost embarrassed to say that we're going to talk about that today. Cause we've like, have we, have we outlived our welcome with original Medicare Alec?
[00:02:00] Alex: Yes, I think so. 
Amy: Yeah, we have right. Yeah. Okay. Fair enough. So I think that what we need to do is move forward and do a little bit of a quick review. Before we have Mike interject a thousand times and tell me I might be wrong, but, we've been talking a lot about original Medicare part, a part B part D we always skipped over part C part C is Medicare advantage, and we haven't really talked a lot about it.
because it's really private health insurance that is offered by private insurance companies that basically by the ability to, manage Medicare patients and. That's kind of not original Medicare, it's like a one stop shop for a, B and D. the nice thing about Medicare advantage, although it's not very popular here in the state of Maryland, where we sit, is that it really offers patients the, some extra stuff that comes out.
Yeah. Side of the regular, the regular Medicare part, a part B. [00:03:00] Part D package. Sometimes it's like meals on wheels and it addresses social determinants of health. And Mike, I'm going to like, just hand the mic to you for a second to talk about what is coming down the pike in the Medicare advantage world, which is possibly going to make everybody in Maryland want Medicare advantage.
So now I'm a little scared I don't want to upset, 
Guest: but 
Amy: yet I don't want to like, make it like so cool that everyone wants it, but you know, well, 
Guest: I mean, it, it, it is, it is kind of interesting because, You know, I can't remember when they allowed it plans to commit to effect. I think it was sometime in the early 2000.
I can't write that yet. I can't remember. But right now you probably should got about a third of beneficiaries receiving Medicare benefits to an ma plan. So. I want you to think about ma as kind of a replacement for traditional Medicare plus other things, and then you all, and then historically people have had Medicare benefits, but they also choose to purchase a Medicare supplemental insurance plan.
You know, ARP has got a really popular one, but that, [00:04:00] that kind of covers the things that traditional Medicare doesn't. as you become a beneficiary. So things like, you know, vision and dental and hearing AIDS and things like that. So Medicare advantage kind of mashes together, those, those two things, it, it basically says when you sign up for a Medicare advantage plan, that provider, whether it's Aetna or blue cross blue shield or United health, or whatever, goes to Medicare and says, You know, I'm now taking care of Mike's healthcare needs.
Mike kind of fits into this traunch of people that will cost you about X per year. I'm going to make it up. Let's say it's $25,000. And Medicare advantage says I'm going to take care of mine for $24,000. And, and by the way, the government likes Medicare advantage plans because they do a lot of the check writing work that the government wants to get out of.
Right. Medicare advantage is also used by the government is kind of a Petri dish for new value based programs and services because it's private industry. And they think that that can happen faster, which it often does. [00:05:00] So that's, that's why the government kind of likes Medicare advantage, but they go there and they say, I can take care of Mike for $24,000 in that extra thousand dollars I can use towards supplemental benefits.
And these are kind of, if you're, if you're out there competing to sell ma plans to people, you know, you're going to dress it up with kind of different features and benefits and all that. So that allowance allows you to get into the supplemental benefit game. Now, a lot of that goes to things like the hearing AIDS, the dental coverage and division carrot benefits, but.
in the last couple of years, and this is all regulated by  CMS. Okay. They, they, they tell the Medicare advantage plans exactly what those stuff will benefits can pay for what they can. But the exciting thing that's happening now is that, The government is recognizing that the vast majority of your health outcomes are not dependent upon clinical care.
They're the social determinants of health. They're your health behaviors. They're the year, they're your access to, food, supports services, all, all the things that, you know, really determine, [00:06:00] Health and wellness, but also safety. And I'm going to go into a little speech here about who costs the system the most.
Okay. So if you are a Medicare beneficiary and you've got three or more chronic conditions, right, you're probably going to cost the system about 50% more on average. there's also what we call functional limitations. These are things I have trouble with walking and dressing and transferring and things like that.
So if you've got three or more chronic conditions and a functional limitation, you're going to cost the system about 330% more on average. So this is about 5% of U S patients, but they consume a quarter of all healthcare spending. Why? Because they trip and they fall. And they go to the hospital, which is the most expensive site of care.
So the government is recognizing this and in the past few years, they've allowed Medicare advantage players to kind of experiment with supplemental benefits that are what they call primarily health-related or I can't [00:07:00] remember the new language, but, can influence positive health outcomes. So these are things like, home care services.
These are things like pest control. These are things like nutrition and food delivery and things like that. And, and, and it's, it's gotten even looser in the past few years, but we're seeing, I mean, there's, I can't remember the exact number of MH plans out there. I want to say it's like almost 3000, but for this 2021 plan here, you're looking at about, about 900 plans offering benefits of this type.
there's also a, another type of benefit called at SIA. Sorry. Assess BCI, benefits. 
Amy: S S B C I. 
Guest: Okay. Yeah. So that is the special supplemental benefits for the chronically ill, which is, which is a kind of a carbon w what they did back in 2018. But, it's basically people who qualified that are very, very sick people.
So there's types of benefits you can offer under an [00:08:00] SSPC I plan. Okay. I am not a regulatory expert. I just sounded like one, but, but we're sort of sort of seeing this, explosion of benefit offerings in both places. So you're seeing plans. I'm just going to go to a, sort of another chart here, cause I want to be really techie.
And so for the people that offered, these types of benefits back in, Back in 2020, you, the majority of them are offering what they call inside home support services, adult day health services were popular, therapeutic massage. sign 
Amy: me up for that one. 
Guest: Yeah, but primarily so, right. So under the primarily health-related supplemental benefits in 2020, the most popular ones were things like therapeutic massage in home support services, support for caregivers, and then the other ones, You know, and the SSP CGI, these are things like more like food and produce pest control.
you know, just these types of services to improve the home environment, quality of life, that sort of thing, [00:09:00] because the government believes that they're going to have an impact. So we're a couple of years into this right now. And, my experience with this, you know, through my, my, my past and home care industry, Was working with a couple of these ma plans to kind of deliver these services to beneficiaries.
I think we're still trying to work things out, but I think the important thing to underline here is that the government realizes that social determinants impact health comes. I know that that HHS is really trying to create an evidence base. For social determinants of health, one that does not rely on a lot of random, you know, long randomly, you know, the sort of prop, what is the acronym?
Oh, 
Alex: RCT the random rent. 
Guest: Thank you. Thank you. Thank you. 
Alex: Thank you guys. Controlled trials 
Guest: and a man plans. His private industry are kind of putting this, putting these out there, and really just, experimenter. but there is kind of a weird chicken and egg game when it [00:10:00] comes to standing up these types of benefits.
There's a lot of things that could work. but, and this is going to come, but, I think a lot of the inmate plans are still kind of working on a hope and a prayer that this stuff is going to actually have an impact. but I think for the larger plans, they, they really do believe in it. I think for the midsize and smaller plans, they're still kind of waiting to see how the big plans do.
but every year, you know, it. More and more plans get into this business. 
Amy: Mike, can I, first of all, amazing data, amazing information. I have a couple of just brief questions as I sort of work backwards from what you were just talking about of the 900 plans that are going to be offering what sounds like some of these types of more jacked up services, particularly as it pertains to home care, which is private duty, which is currently not covered under original Medicare, which I always jokingly say, just get out your American express card.
Do you know, how many hours there you're thinking of offering? Like, is this something that if I'm I'm an adult [00:11:00] child and my mom could switch to one of these plans and I going to say out loud, huh? They're only going to give me four hours a week or they're going to give me 24 hours a week. Like, is there, are there, is there data out there is what they're going to 
Guest: offer?
Yeah, that's an excellent question. So you have to, you have to think about what the budget is for. These supplemental benefits. And you also want to have to think about what the motivations are for an ma plan and an ma plan, I think has, two or three primary motivations. One is to increase the number of people that you have as your customers.
the second. And then the second one is to manage those people at the lowest cost possible. And that means identifying and managing risk. So anything that they're doing, you know, they want to, they basically want to offer these benefits to someone, but in a ways they can get kind of the lower risk. you know, younger or whatever people on their plan and that they can have that benefit forward, or they want to manage risk within the, within the census that they're already managing.
[00:12:00] So on average, the budget for a supplement for supplemental benefits for Sur per person per month is about a hundred to 110 bucks. And it varies by state. Okay. 
Amy: So wait, I'd like to repeat what you just said back to me. They are considering supplemental stuff. But for per beneficiary, only a hundred, some bucks per month, 
Guest: a hundred, a hundred.
I think it's 100, 910 is the average PMPM. So that's the, that's the budget where they have to kind of manage, you know, people's vision and dental and hearing new supplemental benefits. Now you can, you can mix the shells around. So, you know, but, but if you offer, a supplemental benefit to. Myself as, as sort of a profile patient, it has to go to every single one, every single patient that kind of looks like me.
So if you're an ma plan and you've got kind of a, an older sicker, higher risk patient population, then you'll spend budget to, to manage, you know, to, to, to those patients. And you'll offer home caring or other benefits. But, you know, the home care [00:13:00] is by that nature limited, right? Like 
Amy: literally like one hour a week.
Guest: Well, the plan that I was, I mean, we were working on it on a, on a program where they offered about 120, gosh, I bet 120 hours of care per year. If you signed up for that, I think that the, you know, you sign up for it 
Amy: a month. Okay. 
Guest: Yeah. I sort of thought that that was kind of primarily designed for somebody that may have a hospitalization requires home care support for the, about a month after the hospitalization.
Amy: Okay. So it could all be like pushed into a single time. So basically if you offer, let's just say, did you say 120 hours for the year? 
Guest: Yeah. That's that's one example. Yeah. 
Amy: Round it down. Cause I do really like bad math. So like it's a hundred hours for the year at 25 bucks an hour. So they're giving 2,500.
Was it a $25,000? What is that for? How many? Zeros? 2,500. So they're offering $2,500 over the course of a year for home care. 
Guest: Yep. Yeah. Yeah, yeah, yeah. So that, that, yeah, again, that's an exam. Well, that'll, that'll kind of cover it for maybe 20, [00:14:00] you know, about 30 hours a week for a month or something like that.
And that's, that's maybe what you need when you're out of the hospital and because, you know, Mom falls. I fall, I break my hip. I come out of it hospital, you know, most people coming out of the hospital, you know, it required more support than when they first went in. You don't really know what that looks like.
So having it in the home health benefit is, is pretty limited. So when you get discharged from a hospital, you know, you get written for a home health benefit where a nurse might come in and, and, and, and kind of assess you, 
Amy: skilled 
Guest: aid may come in and make them be a one lead or do a bathroom leave or whatever, but you're not having somebody actually consistently in the house for hour after hour, which is often what people need.
And the studies show is most effective, you know? I mean the highest risk person is an older person with a functional disability coming out of a hospital. And going back to a location that you either where they live alone or aware of the caregiving help is [00:15:00] insufficient. That person is going to come right back to the hospital, you know?
So you need this coverage, you need the support. So the home care, when it's introduced. Yeah. It's, let's say it's about. Let let's say you're on that plan about 20 to 30 hours a month, but you have to offer it to everybody and you also have to have it received by everybody. One of the issues that we have is that if you're a plan and you've got people in a rural environment, you know, traditional home care providers, aren't going to send somebody hours out in the card at someone's house to take care of those services because it's really expensive.
You know, the, the, the ma so the ma plans try to bid down the home care providers on their hourly rates. And, it's just not profitable affordable for those home care providers to kind of service that yet the ma plan must service that person. So they're trying to work these things out. You know, if you want to offer these benefits to your beneficiaries, you have to have a network of providers at the ready to offer to be able to deliver those benefits that you've, that [00:16:00] you've legally been contracted.
All right. So. Home care is great. It's absolutely as effective. It's never enough. I think that the, you know, I'm not sure, I can't, I'm not sure if we can go deep into plan benefit design, but, one of the other challenges of, of something like that is that if you are a person that is receiving a benefit like that through an ma plan, you may say, well, the ma plan gives me a hundred hours a year, but that's all I need.
I don't want to pay out of pocket for anymore. You know, the plan should pay for this, you know, when in fact, It's it's often at least today to get enough that you need, you have to go into your own pocket to, to, to, to get that. And that could be like $50,000 on average, really? so there's, there's a lot out there in terms of home care.
It's very effective to have home care. it's it's it helps people stay in their own homes. It helps with risk reduction to be the models that you and I know about Amy, that we work with. but the AMA plan has to kind of, Adopt best practices in assembling a network, [00:17:00] managing and delivering the benefit for efficacy and efficiency.
And most importantly, in a way that gets them to collect the data that not, not only shows is this effective because it is, but how effective is it? The ROI I'll give you another option. Yeah, 
Amy: yeah, yeah. For sure. The ROI is key. 
Guest: All right, I'll give you another example. We've been talking a lot about home care, but what about in home safety?
Right. the bathrooms are the most dangerous rooms in the house. So what about a benefit that comes in puts a grab bar in for two, three, $400 flat boom done. And just the risk reduction potential about how somebody having a grab bar to grab on to. 
Amy: Do they offer that? Have you seen that? Have you seen that as an offering?
Guest: I think it would be a terrific offer. 
Amy: So we should call the head of Aetna right now and be like, Hey, we got a great idea here. 
Guest: Fix the mic. It, 
Alex: if you are an ma patient. and you think you have this benefit of home care, how does that actually get [00:18:00] ordered? And what's the approval process? Like, does it need to be ordered by a physician?
Guest: Yeah. Yeah. Typically that's, that's, that's, that's what happens. So if you want to be qualified for the benefit, at least sort of the models that I've seen is that a physician has, or the home health provider or the home care provider has to sign off and say that you can't perform X number of activities of daily living.
And then that would qualify you to receive the, the benefit. And typically the, you know, home care provider is contracted to provide the benefit. The home care provider does still in with the ma plan and the consumer's kind of left out of it. But the consumer has to the consumer and their doctor provider has to certify that they actually need the in home care, help.
Alex: so how, okay, so, imagine I'm the physician and this is a relatively new thing, right? Cause you don't, you can't order a home care for original Medicare patients. So how do I, as a physician know, like what needs to be in my order or do I just write it on a prescription pad? And then, [00:19:00] what is. Okay.
So if I, and when I order it, do I have to 
Guest: choose 
Alex: a specific home care provider? Or is it a general thing? And then like, what are the actual mechanical steps of somebody ordering this for a patient 
Guest: as soon as you've got, I mean, the ma plan or the, the, the insurer would have the, would have a claim form and you and the doctor, or often the home health provider on care provider would fill it out.
And basically say that I ascertain that, Mike, you know, needs support for walking or transferring or whatever. I think he's going to need, it's kind of like a plan. It's kind of like a plan of care. So they say that I think is going to need this help for two months. And then, the ma plan, would, have a network of providers either through themselves or through a third party benefits administrator.
And these providers would have, excuse me, it would have, contracted with the ma plan. Maybe they'll they may, they provide a discount on their rates [00:20:00] or other types of service guarantees and, you know, the. Beneficiary picks one of these providers and they send somebody out and then all the billing kind of happens absent of the beneficiary, getting involved with that appreciate opens the door to the provider, comes in and does the service and leaps.
So 
Alex: does the doctor need to, I guess know which ma plan the patient is on and then go to the mat plans, a website to get this special form or, 
Guest: yeah. Yeah. Yeah. I mean, you know, the, the beneficiary will put in a call or the doctor will put in a call and then, and then it's just a sign off on a form. 
Amy: Alex, this is actually really interesting because again, it's not knowing what's on your menu, right?
Like, are, this is like the eternal problem, even in original Medicare where, why isn't every patient who could possibly be receiving Medicare part, a skilled home health. Getting that, and then they could now, Oh my gosh. If you're on an ma plan, like how would the provider like, know what's on your menu of possible services?
[00:21:00] Oh. Someone to bring you meals on wheels, somebody to, you know, offer you this, that, or the next thing. And if it requires a doctor's order, it's almost like there's just. No way like that, the consumer and the doctor would all know what's within the rights. And yeah, especially 
Alex: one of the things Mike said, like blew me away.
I had no idea. There were thousands of MAA plans. I thought there might be hundreds but 
Guest: thousands 
Amy: throughout the country though throughout the country. 
Guest: A lot, a lot of that Alex is, is, you know, United health may have a plan. That's branded as. You know this plan in Massachusetts, but it's branded as something else in Ohio, you know, I'm making it, but there are tons of, of, of, you know, smaller entity, you know, health systems may have their own Emay plans.
I know large retirement living providers that have their own ma plans. 
Amy: Sunrise for one I know does have their own Emay plan. 
Guest: So I mean, as a side, we could start one if we wanted to. Yeah. 
Amy: I'm really excited for that [00:22:00] after our debrief. Yeah. 
Alex: You know, you go on these websites, like Zoc doc, where you need to like set, you want to set up an appointment with, you know, some service provider and ask you to like, choose your insurance plan from the dropdown.
And even if, you know, it's like, United healthcare XYZ. There's like 50 versions of United healthcare. I see it. This is what like blows me away. So if you are a fool and you have this ma planned patient in your office, and you're talking about like, yeah, I think you could benefit from this. How. Am I supposed to figure out as a physician as to whether you have this as a benefit, how to do it.
like I just feel like 
Amy: there isn't like, you imagine that this is your, this is your business idea is that you go, what is your insurance? And then you like, look at there's like a website. You'd be like, Oh, Bob Smith has like, whatever, blah, blah, blah. I may plan and be like, Oh my God, Look at all the SDH social determinant of health things, this person could get 
Guest: well, 
Alex: right?
Because you have eight minutes with that patient. Cause you [00:23:00] gotta document and do all this stuff and code and bill, before you go to the next patient, how in eight minutes, are you supposed to figure this out? 
Guest: I remember it. Remember two guys is that, you know, the patient has selected this particular Mia plan.
So the journey that might be, I mean, So the journey actually starts now, right? Open enrollment is either happening or just your opener, right? Correct. So I, so your ma plan that you're already on, let's say sends you a brochure. Sure. And says, Hey, stay with us. Don't switch to the other guy. Cause we've got all these amazing things that we can take care of for you.
Or are there going to be the, you know, they're gonna use the experience of the previous kind of benefit to kind of target new people that don't have it yet so they can do the risk reduction. All right. The one that, I mean, Aetna has been called the essential extras program. Alright, so you sign up for Aetna, the essential extras as a supplemental benefit program, and then you can choose different types of things to be included in the central extra one is home care and other one could be transport.
I'm making this up. Another one could be in the Sarge. So you pick those, those things so that the consumer's going into them, a plant [00:24:00] experience. And knowing that they're picking the plan with these little supplemental benefits they're used in advertising. Yeah. You know, especially the ma plan brokers where you see, I don't know, I can't remember, but one of the, one of the, of football players from back in the day, I'll say, Hey, did you know, Medicare advantage can pay for home care services for you now?
You know, they did this two years ago when only 90 plans were offering this and it was kind of hyped up, but, but they're selling it. That's why they, that's why they do these supplemental benefit programs. These neat create a supplemental benefit programs because they can sell in. Well, they're learning how they can sell into a bigger amount of people with these, these, these cool sounding benefits.
So the 
Alex: ma plans, I'm really curious as to how they approach execution of this. Are they 
Guest: actually trying to 
Alex: get their members to use these benefits? Because they think that if I can get the patient to actually use the member to use the benefit, they are more likely to renew with me as opposed to jumping to a competitor.
And if that is the case, then what I would be telling the member is. Here is [00:25:00] the 
Guest: form you need 
Alex: for X, Y, and Z, print this out and take this to your doctor's appointment, as opposed to expecting the doctor to fix. 
Amy: Are they doing 
Guest: so, so, so let's, let's, let's look back at the extra, the three areas of their motivation, right?
Gaining more men members managing risk, reducing costs. I'd say that right now, the experience has more to do the first thing where they try to get more people into to get the services. And then as far as encouraging use of the services, Cause remember it costs them money. So well, so that's what I'm saying.
I'm curious. Exactly. So then you want to don't encourage use of the services for people that they believe meet the risk profile that don't benefit from the service delivery. So let's say. You know, they may do something more proactive if you've been hospitalized and in your hospitalization code suggests that you're functional, you're functional ability is going to go downhill.
Hey, do you remember? Do you have this benefits? They don't rehospitalized right, right. Yeah. That that's what they'll do. So they'll, they'll, they'll, they'll they'll have motivations to do these things, [00:26:00] but to the process that you described before I got to fill out a form. I got to put this there's there's parallel processes there with home health when home health gets written, which may be outside of the worldview guys, but when home health gets written and home health companies want business.
So, so, so they want to get written this, this, a patient that goes home. They want to encourage discharge case managers to rank them from home health, you know, and, longterm care insurance plans. So, you know, it's way expensive right now. I'm actually working on some really cool next gen, insurance products that are paying for home care.
We just went into consumer testing over the weekend and I can plug it. Maybe if you guys give me a chance, but the idea here is that, longterm care insurance, many people bought back in the day so that if they do need nursing home care support, but they have to pay out of pocket for, if they do need home care support, the insurance is gonna cover it.
But that insurance also involves, and that's where, that's what. Kind of, that's kind of the standard. You need to submit [00:27:00] something where the doctor says you have trouble performing X out of six 80 ELs two out of six, three out of six, one out of six. And that you submit a plan of care in order to get that benefit.
And then the insurance company. It's going to be checking in. They're going to be checking in to make sure that the visits were actually being performed there. They're going to be checking the notes to see if somebody is actually improving and function so that if they no longer have to have six ATLs, which is one of six ADL, then they'll say, Hey, we're going to cut off your benefits.
It will be the same parallel thing within the ma plan world. Most ma plans are building off their Medicaid experience or longterm services and supports a lot of the earlier people that are getting into this benefit where people that had a lot of experience doing longterm services and supports plans for people that were, you know, met, income thresholds, dual eligibles people that are very poor living in underserved communities and things like that.
So they've already generally seen how offering more support for social determinants helps with people that really are. [00:28:00] Very under resourced. Yeah. For people that are now getting into that middle area where the income might be a little bit higher and all that, they're trying to see, you know, how can in-home supports and systems and importantly technology, which I'm really excited about can really move the needle on risk for this kind of next traunch of people.
Yeah. Our, our home care. Yeah. Are 
Alex: providers going directly to physicians and saying, Hey, there's a lot of M a plan patients, in the, you know, in your zip code. and many of them, you know, have this benefit. So, let us help you make it easy to order home care for them. Like, are, are they trying to make this?
I'm just trying to figure out. How, who is making this easy for the physician to know, and to, to do if anybody. 
Guest: Yeah. And I haven't seen that office. I haven't seen it. The home care providers really be that I know that the home care providers, any, any smart providers going to, you know, establish a relationship with a PCP or other person involved in someone's care because they're coordinating care.
I [00:29:00] mean, they're, they're offering and the doctors have to be more incentivized to because more and more. They're going to be judged on value versus quantity and, and they're going to have to reach into the patient home, but I haven't seen anything where a home care provider I'll kind of try to encourage a, I'm not even sure that's legal quite frankly.
Alex: Oh, interesting. 
Guest: Yeah, that's just me. I just haven't seen it. That doesn't mean it can't happen, but I suspect you'd have to do a legal case back before you execute a Brooklyn like that, like that in the home care space. 
Amy: Well, you know, what I think is interesting. I think I want to take one step back and talk a little bit about how ma plans are actually paid for the services that they provide.
So I'm not so Medicare, the average healthy Medicare beneficiary costs. Medicare. I'm going to say anywhere between 10 and $12,000 per year. 
Alex: Okay. 
Amy: Every single time you add. More chronic conditions. That person [00:30:00] would cost Medicare, you know, 20,000, 30,000. And there is some data that there's patients that are obviously costing you a quarter million, half a million.
But like if you average the sickest folks, I think there's somewhere between, I don't know, Mike, maybe, you know, this data between 30 and $50,000 per 
Guest: year. Yeah, I know the percentages, but, 
Amy: yeah, so I think the real dollars are, is about that. And there were some interesting studies that looked historically at, you know, when you add different types of services to different types of Medicare beneficiaries, specifically the sickest 5% you start, you know, if you add.
A house call doctor private duty, home health, home care, you know, Medicare, skilled home health, every single time you add one of these services, you see that, you know, that March downward into sort of, you know, you know, less and less money, 20,000, you know, that that becomes the goal, but we all know that a single hospitalization.
Is about $18,000 a year. So, you know, if you get hospitalized, once there goes your first [00:31:00] 20,000 bucks, 
Guest: right. And the average rehospitalization is about 12 to 14 grand. 
Amy: Correct? So w it's it's expensive to care of the very sick patients. So what I'm trying to sort of get at is the amount of risk that these Medicare advantage plans are taking on the sickest patients.
It's very high, right? Like they have to big uphill climb. Like if you're a totally unmanaged under original Medicare, you are, you may be costing the system. Let's just say $60,000 a year. And the ma plans give you like. Oh, yeah, no, no, no, no. But the man plan is going to get paid a certain amount of money based on how sick that person is, which is why they have to have these like annual evaluation where they add up all the, all of your chronic conditions and you get a score, right.
And based on that score, if you do a really good job scoring that patient, they have nurse practitioners that go out and like, make sure that you've cow. Oh, you have tofu. Yes. Let's make sure we add that. And you know, like, Oh look, you're like, have them think weird on your ear. [00:32:00] Let's make sure we add that in there.
Cause every little thing adds to the points that you can then go back to Medicare and say, Medicare I'm taking care of Sally Smith. I did her point and now you're going to pay me, you know, $45,000 to take care of her. If I can undershoot that, that I get to keep it. 
Guest: So 
Amy: they get to keep that money. And in addition that Stella Smith, depending upon, you know, she chose that MAA plan is now also paying, you know, 400 bucks a month too.
So then add that small amount of money that she's paying every single month to have that Medicare advantage plan. So let's just say that a Medicare advantage plan is going to receive $45,000 from. Medicare. And then she's going to pay an additional, let's say five grand. So they're getting $50,000 to take care of that very sick patient.
It is up to them to figure out how to put all that together. So Alex, to your point, these Emmy plans have navigators. That basically are concentrating. I think too. I mean, I don't think [00:33:00] it's so managed and I'm sure that there's like outliers, but in my experience in practicing, you know, house calls is that if we did have, you know, single case payer agreements, which I would sometimes arrange with different ma plans is that there would be a, a social worker or at least a case manager or somebody that would actually be keeping very close.
You know, a close eye on that patient who would be saying, Oh, you know, she gets this benefit and this benefit and this benefit, we need to maximize that. So I think what happens is they take the sickest of the patients and they do kind of highly managed them. So to your question, how would a doctor or a patient know, Hey, listen, you have the home care benefit.
It's because they have community. Health workers or social workers or whomever that are managing and trying to match that person up with people. 
Guest: Yeah. 
Amy: Well, I'm not saying, I'm not saying it would be. Obvious for the regular Joe blow ma patient. But yes, 
Alex: is that there are so many different ma plans. So I would assume that they [00:34:00] have different benefits at diff with different thresholds for those benefits.
So if you're in a, if you're in a region where there's a lot of ma plan options as a physician, how do you know like. 
Guest: How do you keep track you 
Amy: can't, there's no way 
Guest: the pain, the patient has. 
Amy: The patient has to 
Guest: call up the, you call it the number on the back of the card. You know, those are the benefits. I mean, there's really to Amy's earlier point, there's really a Goldilocks thing that, that, ma plans desire with the combination of benefits, right?
They want to look at you. They want to look at your risk level. They want to make the case that you fall into kind of a higher trash. They can get the higher reimbursements they want to. Offer a portfolio of benefits that attracts kind of the right people into their plan, that they may be able to graduate up or down or whatever, but there is what they call adverse selection bias or, or, or because if you offer, if you offer a home care benefit, then [00:35:00] they don't want old sick people suddenly saying, Oh my God, I'm going to, I'm going to join this thing.
Cause I'm going to take care of this benefit right away. Right. And also, so they're learning about the design of these benefits and what, what the different leavers are and, and, and, and how it's going to get into the mix. And I'll, I'll actually see you raise you on this because as they just announced this year, something called the V bid model for Medicare advantage.
So CMS has been offering value based. Programs to primary care to health systems. They've got the primary care first program for primary care medical docs. They've got the direct contracting model. They've got other types of value based contracts. The bigger health plans and practices have gotten involved in, but now they're extending that into Medicare advantage.
So Medicare advantage can now get value based payments from CMS if they keep the risk level 
Alex: and the, 
Guest: whatever the measurements are, usually it's hospitalization rates. Below a certain threshold and they can get bonused on that. So now they're looking at, at, [00:36:00] at the efficacy, that's the big thing that's happening here, that the chicken and the egg thing is the data.
All right. We were only a few years into this, so we only have a couple of, I mean, I know that BMA plans that are doing things like home care benefits are seeing that folks that, that have the home care benefit, whatever, some sort of impact. Has been done, but then how much impact for ROI? Right. I think there's a lot of different technologies out there that cost a heck of a lot less than home care services that might give you the same ROI, but then you have to go in and be tested.
I think that a lot of the, a lot of the forward thinking ma plans will go into pilot with this stuff. I think that the data is good. I think CMS and HHS, you know, HHS. Are, supporting these types of investigations. So there's that navigating that whole world for an ma plan can be a bit of a challenge.
Yeah. Can we pause for a second and 
Alex: talk about from the patient's perspective, from the member's perspective? w w Amy, you and I have previously spoken about like the 20% copay or coinsurance for a regular [00:37:00] part D service. so when a member chooses an AMA plan, so, we did touch on the fact that there is still a monthly premium, for them to pay.
Guest: But 
Alex: what about copays and coinsurance? What are, I'm 
Amy: sure they have them there. Nothing's free. Right. Like, it's just like, 
Alex: Oh no, 
Amy: it's going to be totally different. It's an insurer. It's a private insurance company, right? Like 
Guest: it's a plan, but like you're still additional net stuff plans or, you know, one of their features is that we can, we handle your copays for you.
So medical is supplemental insurance. One of the other features is, you know, you have, you have Medicare, but that's not enough. So the Medicare plans. say we'll handle the vision dental, but also cover your RX copays and other types of copays. So that that's kind of folded. Right? 
Amy: So just, just to me, just to be careful here, let me, let me just make a correction in general.
Most Medicare part B supplemental plans actually don't necessarily cover. [00:38:00] Vision and dental that's the, that is actually, I think a little bit of a, I don't want to perpetuate that too much. There probably are some out there that do, but not most. secondarily, I think that the key here is that once you are in a Medicare advantage plan, you are literally in private insurance.
So think of what a private insurance plan looks like. There's going to be limitations and we may not call them copays, but there's uncovered services. Right. And my guess is there are some copays when you walk through that door 20 bucks, they want to disincentivize utilization. 
Guest: Sure. Well also, if there's there's, I, I like to see copays on things like, home care services.
So because if, if I'm a home care services provider, part of what an ma plan might say to me is that look. This is a great gateway that as soon as the ma plan benefit is done, then you've got a chance to retain this person under private pay for. Cause you know, [00:39:00] it's never enough. I know a hundred hours of home care a year where there's never enough, but the conversion rates that you typically see from a Medicare advantage funded service to a private pay service is probably under 10%.
When somebody, when somebody, if somebody gets something for free, they don't value it. Right. Hey coach. So cool. One of the, this is why copays exists because yeah, they, they do, they are designed to, make people think about when and how they're going to use these services. Cause they have to pay a minority out of pocket for that.
But if I'm a home care provider and I've got an Emmy plan saying, you know, I want to see a five per 10% reduction in your hourly rate. And I'm already working with a, you know, a 10% net. And so you're basically cutting half my profit out if I, if I, if, if I go with that. But if they say, well, look, you know, we can spice it up by saying, this person has to pay $5 an hour out of [00:40:00] your pocket.
Well then. Okay. Yeah. Now I can offer you a $20 an hour service, including the case management and all the rest of it and this person, and then the $5 is covered by the patient. And then we can kind of work and they've got skin in the game that way. And that's, that's, it's supplemental, it's a supplemental benefit.
And supplemental means that, you know, it may not entirely be covered. Right. 
Amy: So it's limited. It's like it's got limitations to it. It's got, you know, Guardrails, you can't just get it all. 
Guest: There's two. I mean, insurance companies is they throw everything at, I mean, you walk into the home of an elderly person and you see sleep, you know, sleep apnea equipment sitting on the ground or are something still on the box.
And it, Oh, when my insurer, my doctor sent me this. And I haven't even used it or anything like that. I mean, there's a lot of frivolous stuff. 
Amy: The waste I'll tell you when I was a house call provider, I once walked into a house and I was like, Oh, here's a quarter of a million dollars worth of durable medical equipment.
You know, there's like three bariatric, you know, [00:41:00] beds and three bariatric wheelchairs and electric wheelchairs. It was like a DME graveyard of sorts. Like you just couldn't believe all of this. Stuff. Cause every five years you get more, you know, it's like the lifetime's over. Get more. And then, so if you're disabled for 20 years, you're just, it's just tremendous amounts of wastage in some ways.
Guest: Yeah. Yeah, no, I looked at her, I, you know, my, you know, my wife had her, had her, you know, had her fractured her ankle early this year. And you know, the, the boot alone was 550 bucks. And all they did was sort of stick the boot on her and cut the cut the, the Velcro. And that was kind of a service. And, you know, it's all, it's all, well-designed, you know, we know what we know this.
I mean, this is not a, you know, but, but I think the important underlying thing is that yes, they're they're yes, they have to be designed sensibly. They had to be designed in a way that kind of balances, the, the, the, the risks are the people that are receiving the services are actually getting it. Like, I I've.
Heard of, or experienced [00:42:00] things where for a home care benefit, people think it's the cleaning service. You get the diet, they get the doctor to sign off on it, but then the home care provider shows up and they're not doing support for ATLs. They're, they're just basically tired hang up the house because that's what this year.
Exactly. I think that's what the beneficiary thinks it is. And that's not part of terms of service. 
Alex: So, we started off with is that ma plans offer all these supplemental benefits that original Medicare does not, provide. So I think it's important for us to also clarify, you know, given that these 
Guest: extra services 
Alex: are provided under certain, you know, thresholds or requirements, what are the reasons, what are the reasons that a member should not.
Choose NMA plan over original Medicare. Like what are the downsides of an ma plan? 
Guest: It's a great, I mean, 
Amy: okay, I'm going to let you, Mike have at it, but as a provider, former provider, I'm, I have all sorts of really great ideas as to why, but Mike, I'm going to let you have at it. 
Guest: Well, [00:43:00] traditional Medicare's kind of a single source of truth and, and Medicare advantage plans, you know, we can continue to kind of perpetuate this, getting paid in 40 different ways or, or, or whatever.
So does it, does it contribute to whatever the, you know, the, the inefficient. The inefficiency in the healthcare system that's born out of employer based health plans basically just continues that alone. you know, so, but I mean, they're getting more and more popular because people like them and the government's encouraging this ship.
I mean the government, again, they want to get out of the check writing business. They don't like the bureaucracy of having to process claims and do all this and that. And the other private industry can do that for them. Great. So you're, that's why you're seeing, it's estimated that in four years, about half of beneficiaries will be on an exit plan.
Right now it's about a third. 
Amy: So I'm going to add to this. So on our website, after this is over, we are going to have a, a great, graph from the Kaiser family foundation that looks at ma participation rates by state and sort of national [00:44:00] participation. Okay. and Alex, I'll send that over to you so we can put that up on the website.
But I think that the important thing to understand is in a place like Maryland. Okay. So I'm going, just going to go state by state. I actually was focusing on States with the letter M Maryland, Minnesota, you know, all those, you know, Massachusetts. We are the lowest M state slash we are the lowest state, probably in the union, in the United States, that has a Medicare advantage.
Between eight and 12% of Medicare beneficiaries in the state of Marilyn participate in a Medicare advantage plan because we are a, Medicare, we in a weird Medicare place, our hospitals have all joined together to be part of a, sort of an exceptional program in the, in the country. We, we are not incentivized to have ma plans in our state because the hospitals have come together to try to reduce costs in their own way and are actually controlling costs.
Guest: Under a capitated model. Yeah. 
Amy: Yeah, absolutely. So there's, there's [00:45:00] that, but if you look at almost every other state, which is why it's always so hard, when we start talking about policy and all this other kind of stuff, for me to always envision what it looks like, and, you know, Minnesota and Massachusetts, where it's like 20 to 40% and sometimes up to 60% in some zip codes is my guess of people participating in Medicare advantage.
So it's, everything's really different, but from a provider perspective in a place like Maryland, When you're like cruising along and you know, you know, the gears are all moving and the oars are all in the water and you're sort of moving along, you're taking regular original Medicare, and then somebody comes along and it's like, boom, you, you run them through your little checker to see what kind of Medicare they have.
And you're like, Oh, you have blahdy, blah, Medicare advantage plan. You go, you know, I'm really sorry, but we don't take your plan. 
Guest: Yeah. So 
Alex: I think that's what a lot of people don't realize. And I didn't realize it either until we, we talked to. Yeah. Which is that the F the wind, [00:46:00] if you have an ma plan as your, your version of Medicare, Your, your options for your physicians might be significantly limited because for the physician to take your Humana and a plan or your, you know, 
Amy: Johns Hopkins or whatever.
Yeah. 
Guest: Position needs 
Alex: to have filled out 
Guest: a 50 page 
Alex: application to enroll in credential in the Humana. Plans. And then in the Aetna plans and a lot of doctors say screw that because of multiple reasons, it might be burdensome. maybe they've already done three or four other plans, and that's all they're going to do.
Maybe in their state. There aren't a lot of Emmy plans. It's just not worth their time. So, but from a member's perspective, it, it could limit the scope of providers that you could see who would be in network. 
Amy: Correct. And as a real life example, I happen to just know this ecosystem very well. In the general area in which we are taping this podcast.
the house call providers that are in this area [00:47:00] will participate with an, a limited way with some PPE owes. If you are in an M a plan, you have to end up with these things called single case agreements. And they'll say, okay, well we'll okay. You for 12 visits and, and the administrative burden of keeping track of such a thing when like Medicare is, you know, thank you, Medicare, you just send it off to a clearing house.
In two weeks later, you get a check with these types of things, you know, Oh my gosh. And this one's in this Mia plan and that one's NMA plan. How many times can we see this one? And how many, if the administrative burden is almost too much to start. You know, diving into too accepting these plans because just too much, too, too much.
But just to say, if you are somebody who is in the position where you may need a house call provider, And you live in the area in which we are in you're out of luck. There are not many slash I don't think any house call doctors, nurse practitioners, or PA's that may take these Medicare advantage programs.
[00:48:00] There may be some, but it's, it's certainly limiting in terms of the number of the providers that you can. 
Alex: Let me make sure I understand what you just said. You're saying, because ma plans are essentially the same as other for-profit insurance plans. they are more motivated for creating roadblocks to care than the quote unquote general government, you know, regular, original Medicare.
So they do create those roadblocks then. So 
Guest: they create all sorts of hoops for the 
Alex: doctor to go through and, and they're different. This Emmy plan has these hoops for this program. 
Guest: I'm, I'm Switzerland in this conversation, but guys, I don't know of any of this, you know, this is it, this is new for me, but I mean, the, the ma plans are contracted to provide Medicare services.
You know, they can't color outside the lines in terms of, you know, the Medicare services that they provide, you know, that's their contract. They're legally obligated to cover someone's healthcare needs exactly the same as, as Medicare would have. 
Amy: Right, but they ha but sometimes what they do the [00:49:00] provider side is yes, they're going to say, Oh, sure.
You know, here, this and that XYZ Medicare advantage plan, we do offer house calls. So they may in fact contract. On by one Z twosie basis with different providers that are out in the community. And the way that they do that is they, like, this is what would happen for me. I would get a call from a care manager at that Medicare advantage program.
They would say, Hey, dr. Schiffman, you know, look, we've got, you know, Mrs. Smith and she lives here in Rockville. can your practice take care of her? She just got out of the hospital, you know, she usually sees dr. You know, Somebody else, but she can't make it out of the house anymore. We would like to do a single case agreement with you for 12 visits.
and you know, we think it should be, you know, one time per week, they'll dictate how they kind of want you to sort of see that patient. And, and then you kind of have to be like, Oh, hold on 99.9, 9% of the time I'm doing this task. And now for this one patient, I'm going to have to learn how to do it their way.
They'll [00:50:00] sell it their way, keep track of it their way. So that one patient ends up sucking up a tremendous amount of, you know, mind and cognitive and administrative time of a practice. When you do, you know, this thing, 99.9% of the time. Pretty good. Darn. Well, I am distraction. 
Alex: This is kind of crazy. So hold on.
Are you saying that you were not enrolled in that ma plan and they reached out to you? 
Amy: Correct care. Yes, because they, they have to provide certain services. They know that they exist and they know that they'll pay for them, but they don't have them in network. So they'll like, have some things they're like, okay, for this exceptional patient, we will find somebody to do this thing.
And so they would reach out to me. Yeah. So there's like, You know, like a panoply of different ma plans, like maybe like 10, maybe less. I think there's less than the state of Maryland and the, in each one of them individually would at one point had at one point reached out to me to take care of their high utilizers, you know, but one at a time.
So you never got a real flavor of it. And then [00:51:00] you would try to figure it out. I'm not even joking. There was one point where I was like, I kept sending them CMS, Medicare 1500 form to this person, to that person to then no, I'm sorry. You did it wrong. No, you got it just so right. So you, so you would never get paid.
Well, this work and it was actually the most painful work because interestingly, they would have a care manager. So now not only are you seeing the patient, but now you're talking to the care manager, you're doing a thousand different things for this person at the end. They're like, Oh, sorry, we're going to make it so hard for you to get paid.
That you actually kind of just roll over and give up. Yeah. Okay. Nevermind. That was a waste of time and learning curve. Thanks so much. We're working with another Emmy plan again. I'm not saying that it's like that now, and I don't want to bad mouth anybody, so I'm not going to use names, but like. A lot of these, they're just, it's not coordinated on the revenue cycle management side.
So once you don't get paid for what you, all that work that you've done, which you enjoy doing, right? Like you enjoy taking care of people when you're a doctor and you enjoy making sure that somebody is going to be safe okay. In their home. [00:52:00] But you also are not take your time looking at it. Like they are from an administrative side, which is like, Oh boy, it's my 11th visit.
I better do everything I can. And maybe it's time to renew my 12th. You know, visit to her, you know, it, they, it, it's so hard to take care of people when you're, when there's one office and that's just a reflection on good business practices in general, but like, yeah. 
Alex: So does anybody do either of, you know, how much churn there is, with, with members switching or, or opting out of an ma plan after being there for a year?
Is it, is it high or low and how much has that on their radar? 
Guest: I don't have, I don't have those numbers off the top of my head, but that actually leads into another interesting area of risk for the ma plans, which is you're sending somebody into the home. That's a representative of your ma plan. So let's say that you're an ma plan and you have a home care benefit and you demand because [00:53:00] there's, this is largely based on their experience with home health, but you demand that the provider gives you a discount.
And a lot of people get kind of washed up that way. If I'm a home care provider and I'm getting paid next week with a credit card from my private pay clients, and I'm working with a set of caregivers that might be as rare as hen's teeth in my market. So I'm essentially selling all I can. With, with, with, with my, with my benefit.
Now you're saying that I got to take a 5% discount and wait 60 days to get paid. We'll fill you in all your forms and blah, blah, blah, blah, and do this. So you may not get a lot of the higher quality providers coming on board with you. And now you've got a person coming into the home that may be substandard, and it's not that, you know, Joe's home care screwed up.
It's that entered name? Ma plans screwed up. So that's part of this kind of risk where, you know, they want to retain their members. They want to get members in. And with these really cool sounding benefits, they want to make sure that the benefits are used by the people that need them the [00:54:00] most. But they also want to make sure that the ser services, the delivery is one where they're not going to get burned.
I mean, we hear stories all the time about, about in home care aid, not often, but Ray, this is rare, but you know, anybody's been around for a while. I'll have a provider that steals from their clients. You know, you're going to have that. So then you have this risk and risk mitigation, risk management.
There's a lot of it, but, but you know, when you have a service provider come into the home and the AMA plan said, you know, you have to choose from these service providers and that sub sub quality, that's going to be a risk that we're going to switch to another plan. 
Amy: So there's, there's the churn, I guess, of the vendors that are related to the ma plan, but then there's the churn of the patient.
And I can speak to this, Alex, there is a certain percentage of people that are highly dissatisfied with being an ma plan for some of the reasons that we've discussed. Oh, what do you mean? My provider doesn't take that Mia plan. Like I signed up for it. It looks so pretty on the TV set or the daughter accidentally signs them up or they sign a piece of paper that actually [00:55:00] signed them up.
Right. Medicare has a way for you outside of the, you know, October to December time to get out of a Medicare advantage plan, you can always opt out yet. You can go from MH back to original Medicare at any time. 
Alex: Interesting. And I'm sure there's some hidden 20 page form to do that. That would take, 
Amy: I have no idea.
I believe I would call 1-800-MEDICARE. 
Guest: Is that a real number? You guys are, you guys are really cynical. 
Amy: Well, no, Alex and I have actually talked about this at nauseum, which is actually the six. The number one I have decided the number one way to success in business is the willingness to fill out forms.
If you are willing to fill out forms, you will succeed. People are so turned off by forms. Like if you want to disincentivize any activity, just bake their form, just put a form in front of it. And you will literally see participation go from a hundred percent to 3%. You're like, Oh no, that's a very ugly, very unpleasant [00:56:00] form phobia.
Alex: Pass 
Amy: the form, 
Alex: encrypt the form, make it so that you don't know whom to send the form, 
Guest: right? Oh yeah. And you'd only 
Amy: be filled in on certain versions of Adobe. Like if you do it on a Mac, it actually erases all the content as it get sent. Like it's just, you can't even imagine. What's in my coffee. I swear.
It's it's just too much. So yeah, no, I it's 1-800-MEDICARE, I think then, then you like click on this one thing and there's a whole slot. We can maybe direct people if they would like to leave their ma plan. We'll we'll put that link on the website too. 
Alex: So one of my good friends, Reza, lov, who, knows everything about value based care and who we'll have on the podcast soon.
he told me something about any plans that I had no idea about. He said, that yes, many ma plans, you know, they get paid for patients in different tranches. So they're basically taking risk on those patients. Right. But many, some of them actually then delegate the risk to [00:57:00] certain medical 
Guest: groups.
Alex: So they take, their, you know, thousand members and it actually, contract with a large medical group. And net transfer the risk to these medical groups. So there are medical groups, 
Amy: PCMH model, medical home models. 
Alex: Yeah. But those medical groups are taking maybe 80 to 90% of the 
Guest: revenue and the risks.
Alex: I'm getting some feedback here on the audio. but I did not know that either of you has any experience with delegated risk. 
Amy: I mean, I think the PCMH model that one of the local groups in our area has a very, they basically, it's a, it's a medical home model, which says, if you're going to take our insurance, we don't just give you, it's no longer fee for service.
They no longer have a fee for service model, even though they sound like they're fee for service. If you are a participating provider, it sounds like you're about to be a fee for service provider. But in fact, you have to [00:58:00] like fit into this medical home model, which is a completely. You know, similar idea, which is you're taking a certain percentage of risk 
Guest: for that patient, even though, 
Amy: even though it's not an ma plan or even it's just private.
Yeah, 
Guest: go ahead. It's all, it's all about risk management because you know, the ma plan can't put their hands on the patient. They have to incentivize the people that put their hands on the patient to do a good job. You know, I mean, a good example of this is if you're under traditional Medicare and you were a home health provider, back in the day, you could, you could make a whole bunch of money on, on, on Medicare, despite like wrapping somebody service and kind of doing this and doing that.
And then Medicare got wise to it and now it makes all the home health care providers, you know, reauthorize the plan of care every 30 days. And do electronic visit verification. That's an important when they were charging for visits that never got into the house. So that was more of a, that's more of a, it looks sort of cost management thing, but yeah, for, for ma plans, sure.
Try to incentivize the doctors to take on risk. And [00:59:00] the doctors thinks they'll probably will get rewarded for the quality of care. 
Amy: Yeah, no. I mean, I think, I think the reason that we are having this really interesting discussion is because we, we do recognize that in Medicare advantage, the risk of taking on a very sick patient can be mitigated through identifying certain social determinants of health and the area in which you are an expert, is this home care as it and technology in the home.
And all of that all is a risk, all are risk mitigators. And imagine if you could. Just avoid a single hospitalization or rehospitalization, the effect, the financial effect that that company would feel is very, very significant. So I really look forward to seeing how this is going to play out because based on the fact that 38% of people think that original Medicare pays for home care.
This is only just going to confuse people, but that's fine. So Emmy plans are going to say, yeah, we pay for home care, but okay. Yeah. It's not real. It's not like [01:00:00] significant and for the rest of their lives. And it's just very limited. So I will be so interested to see over time with the ROI is on the sort of time limited little alley clots of time, will be on what people are.
Going to see in terms of reduced re hospitalizations 
Guest: and importantly, you know, what sort of benefits or assets are? I think the technique we haven't had time to talk about technology, but I think that the technology solutions are incredibly promising because comparatively for the ROI that you see the risk reduction ROI, sending somebody into the home to do something one time to do something over and over again.
You know, so one time to install something and maybe do a home safety check and risk reduction, blah, blah, blah. And I have on the way monitoring versus having a physical person coming to the home. What's the relative risk reduction for those two models against [01:01:00] costs. 
Amy: Yeah. Yeah. I'm really excited for our next podcast.
When you come back and talk about, the concept of social determinants of health and micro social determinants of health. 
Guest: Oh my God. Yeah. You know, I love to talk, so 
Amy: I'm so excited for that. so I think we're, Alex, do you want to do like an Alex summary? Can you do an Alex summary? 
Alex: Yeah, sure. okay.
So to recap some basic concepts here. So, when you, as a member who it's about to choose, what sort of Medicare plan you want to 
Guest: choose, 
Alex: you can either choose original Medicare, or you can choose a M a plan, which is going to kind of be a combination of. the different pieces of, of, Medicare.
so it's basically a private version of original Medicare administered by a private insurance company like Humana or at night, they're getting a certain amount of money, to provide, yeah, at least the kind of the minimum. [01:02:00] Medicare benefits. And then they add on all sorts of kind of sprinkles on it yeah.
To attract you. but then as we learned today, actually getting those skills, wrinkles have extra benefits. Those supplemental benefits, can be somewhat challenging. it can be a little bit challenging to figure out what you qualify for. It might be more attractive than what you might actually get.
It's not necessarily easy for the doctors to know what you qualify for and for them to order it. and, but, but to, to some degree, the ma plan is incentivized to actually. Provide these extra supplemental benefits, because one, they hope there's a real ROI on it. when it's administered, when it's given to the right members, right.
Who actually would benefit from it, and they are very much incentivized to reduce churn and keep you on the plan, because they get essentially a monthly payment from the government to provide this to you and they are in the business of having more members. So, I think. When [01:03:00] done well, an ma plan, be a really great option.
if I were a member trying to choose one, I think one of the first things I would do is to ask myself is, do I have a primary care doctor to whom I'm wedded and I really want to stick with, and if I do let me first make sure that they accept my ma plan before I even. Think about swapping out and let me find out if they're, if ma plans are very prominent in my state, because if they're not, then I would be significantly reducing my care options in my state, but in some States, It might be that many doctors take almost every Emmy plan and it's not a detriment to getting care at all.
So anyways, that's
Guest: Medicare, Medicare plans are held to quality standards. They're held us through star quality rating centers. So you can, you can go on the web, and, and review your ma plans. Quality rating. 
Alex: Absolutely absolutely great idea. [01:04:00] Right. Well, I want to thank you, Mike, for, for, teaching us so much. And, this was a really great discussion and I I'm absolutely certain we're going to have you on again, to going to deep dive on the social determinants of health, which is another fantastic topic.
Guest: Yeah. 
Amy: So, yeah, this was great. Thank you guys so much. 
Alex: Alright. Have a good day. 
Amy: Alright. Don't forget. Www dot. Mastering medicare.net. And we will put all of our, new fun data pieces is up on the web. Thanks so much. Alright, bye bye.