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Do Enhanced Medicare Programs Make Sense?

Dr. E, guest blogger

Medicare advantage I have an elderly relative in a nursing home.  She has Medicare, of course, and secondary health insurance provided by the state she lives in, a state with excellent health care coverage.

I recently got a phonecall from a social worker at the nursing home.  She told me that they had a few openings for residents to join, at no cost, an Enhanced Medicare Program available to nursing home residents and wondered if I'd like to sign my relative up.  "What are the pros and cons?" I asked.

The social worker seemed stunned.  Since she presents the option as a gift your relative has been chosen to receive, she is used to most people saying "thank you" and signing right up.    She was hard pressed to answer my question as well as others I asked.  She finally gave me the local and national information phone numbers for the Enhanced Medicare Program she was promoting.

What I learned from making those calls is that Enhanced Medicare Programs for nursing home residents are run by several different private insurance companies, who have persuaded the Federal government, with questionable and self-serving studies, that these programs reduce patient hospitalizations and thus reduce Medicare costs.  From what I've learned and seen, however, nothing could be further from the truth.  That insurance lobby in Washington must be way more powerful than we've been told!

 I was told that the way these enhanced plans work for nursing home residents is that Medicare pays a significant monthly fee to these companies.  In return, the only added benefit for my relative is that an outside nurse practitioner would visit my relative just once a month.  We do not know how long the nurse's visit is or what the qualifications of the nurse practitioner are.  And, I wondered, do the nursing homes get a fee for every resident they sign up?  The social worker seemed more like a saleswoman for the program than an informed patient advocate. 

But here is the main question:  since licensed nursing homes have nurses round the clock and aides who see residents 24/7, and since these nursing homes also have doctors who make periodic visits and are available for phone consultations 24/7, and since Medicare and secondary insurance pay for everything else, how can this brief, just once a month visit, which costs Medicare a great deal of money, end up saving Medicare anything?  

I did my part to reduce questionable Medicare costs incurred by insurance companies in this country: I declined enrollment in the plan for my relative. 

The bottom line is that there's no substitute for your being totally involved with your relative's health and care in a nursing home.  Call the relative daily, if possible; stay in  constant communication with the nursing home staff/doctors; and and make unannounced visits as often as possible.

I'm Dr. E., Ph.D.   For more information, click on the following resources: 

Medicare Meets Mephistopheles

Healthcare Fraud:Auditing and Detection Guide 

Medicare and Medicaid Fraud and Abuse,2009 ed. 

The Political Life of Medicare  

Reforming Medicare:Options,Tradeoffs and Opportunities


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