THAN ONE WOULD OTHERWISE EXPECT.

IT IS APPROPRIATE THAT ON THE 60th ANNIVERSARY OF WHEN MEDICARE BEGAN OFFERING COVERAGE, THAT WE DISCUSS THE TWO GOVERNMENT SPONSORED HEALTH INSURANCES MEDICARE AND MEDICAID THAT ARE OUT HERE.

GOVERNMENT SPONSORED HEALTH INSURANCE IS NOT A NEW IDEA.

IN THE EARLY 1920s, SEVERAL EUROPEAN COUNTRIES INS INSTITUTED A TYPE OF NATIONALIZED HEALTH INSURANCE.

AROUND THE SAME TIME, COUNTRIES INSTITUTED NATIONALIZED HEALTH INSURANCE.

IN THE U.S., NATION HEALTHCARE IN THE FORMS OF FUNDS WERE DEVELOPING.

TEDDY ROOSEVELT PROPOSED A TYPE OF NATIONAL HEALTH INSURANCE IN 1912 IT WASN'T UNTIL HARRY S. TRUMAN 1947 INAUGURAL ADDRESS THAT A FORMAL NATIONAL HEALTH PLAN WAS PUT FORTH.

TRUMAN FELT THAT HEALTH WAS A MATTER OF NATIONAL SECURITY SINCE OVER ONE MILLION MEN WERE INELIGIBLE FOR MILITARY SERVICE BECAUSE OF ILLNESSES.

NOT INCLUDING PROGRAMS FOR OUR VETERANS, THE TWO BIGGEST GOVERNMENT HEALTH INSURANCE PLANS ARE MEDICAID AND MEDICARE.

TODAY WE WILL TALK ABOUT MEDICARE AND NEXT WEEK WE WILL DISCUSS MEDICAID.

THE TASK OF WALKING US THROUGH THE MAZE OF ACRONYMS ABBREVIATIONS AND THE ALPHABET SOUP THAT IS MEDICARE WE HAVE Dr. KEVIN MARTIN.

Dr. MARTIN IS A GRADUATE OF THE VANDERBILT UNIVERSITY SCHOOL OF MEDICINE WHERE HE ALSO DID HIS CORE GENERAL SURGICAL TRAINING BEFORE TRANSFERRING AND COMPLETING HIS TRAINING HAD AT BAY STATE MEDICAL CENTER IN SPRINGFIELD MASSACHUSETTS FOLLOWED BY A RESEARCH CLINICAL FELLOWSHIP IN THE DEPARTMENT OF SURGERY AT THE UNIVERSITY OF CINCINNATI SCHOOL OF MEDICINE.

PRIOR TO RETIRING, HE WAS A PRACTICING VASCULAR SURGEON AT THE AT ST. ELIZABETH HEALTHCARE SYSTEM.

FOR 26 YEARS, Dr. MARTIN SERVED ON THE MEDICARE CARRIER ADVISORY COMMITTEE FOR THE COMMONWEALTH OF KENTUCKY AND HE IS NOW AN ADJUNCT ASSISTANT PROFESSOR AT THE UNIVERSITY OF KENTUCKY COLLEGE OF MEDICINE.

Dr. MARTIN, KEVIN, SEEMS LIKE WE HAVE BEEN TALKING ABOUT MEDICARE AND MEDICAID FOREVER AND A DAY.

HOW ARE YOU FEELING, MAN?

>> I'M DOING GREAT.

THANKS FOR HAVING ME.

>> WELL, NICE TO BE HAD SOMETIMES I THINK.

IT'S NICE TO BE HAD.

WE TALK ABOUT MEDICARE AND MEDICAID.

I THINK SOME OF US THINK THESE TERMS ARE INTERCHANGEABLE BUT THEY'RE TWO SEPARATE PROGRAMS.

TELL US ABOUT THAT?

>> IN 1965, PRESIDENT JOHNSON SIGNED THE BILL THAT ESTABLISHED BOTH MEDICARE AND MEDICAID.

THEY'RE TWO DIFFERENT PROGRAMS.

MEDICARE AS IT WAS ORIGINALLY SET UP WAS TO COVER PEOPLE THAT WERE 65 YEARS AND OLDER AND THEN THROUGH THE YEARS HAVE BEEN MULTIPLE EXPANSIONS OF IT TO INCLUDE PEOPLE THAT HAVE BEEN ON DISABILITY FOR MORE THAN TWO YEARS, ADDING ALSO THE END STAGE REFUGEE FAILURE OR KIDNEY DIALYSIS PROGRAM.

IN 1988 THEY STARTED THE PRESCRIPTION DRUGS COVERAGE.

AT THE SAME TIME, MEDICAID WAS SET UP AND THAT IS A PARTNERSHIP BETWEEN THE FEDERAL GOVERNMENT AND THE STATE GOVERNMENT.

AND THE STATES DO HAVE INPUT SO THAT THEY CAN CHANGE SOME OF THE RULES AND REGULAR LAWTIONZS SO THAT-- REGULATIONS SO THAT MEDICAID IS DIFFERENT IN EVERY SINGLE STATE.

MEDICAID IS BASICALLY SET UP FOR MORE OF THE INDIGENT PEOPLE.

BUT YOU CAN GET ON TO IT UP TO ABOUT 138% OF THE FEDERAL POVERTY LEVEL OF YOUR INCOME.

NOW MORE RECENTLY, THERE HAVE BEEN OTHER EXPANSIONS OF IT SO THAT THROUGH THE AFFORDABLE CARE ACT, THEY CAN HAVE STATE MARKETPLACES WHERE YOU CAN PURCHASE OR START PAYING PREMIUMS TO GET ON TO MEDICAID SO THAT YOU'VE GOT HEALTH INSURANCE.

IT ALSO COVERS A LOT OF AID TO DEPARTMENT FAMILIES WITH CHILDREN, THINGS LIKE THAT.

BUT IT'S BASICALLY TO HELP THE LESS FORTUNATE.

>> ALL RIGHT.

WE'LL TALK MORE ABOUT THAT PROGRAM NEXT WEEK IF YOU ARE STILL GOING TO BE WITH US.

BUT OTHERWISE YOU MAY GET TIRED OF TALKING TO ME ABOUT THESE THINGS.

BUT WHEN WE LOOK AT MEDICARE, IS EVERYONE AUTOMATICALLY ELIGIBLE TO PARTICIPATE OR ARE THERE CERTAIN CRITERIA THAT HAVE YOU TO GO THROUGH?

>> WHEN YOU TURN 65, YOU CAN SIGN UP FOR MEDICARE AND IT IS RELATIVELY EASY.

YOU CAN SIGN UP ONLINE.

BUT NOT EVERYONE NECESSARILY SHOULD SIGN UP AT THAT POINT.

SOCIAL SECURITY FULL RETIREMENT AGE IS NOW 66 TO 67.

AND SO A LOT OF PEOPLE ARE WORKING PAST THE AGE OF 65.

IF YOU ARE STILL WORKING AND COVERED UNDER EMPLOYER HEALTH PLAN, THEN YOU DON'T NECESSARILY NEED MEDICARE.

AND IF YOU DON'T SIGN UP FOR IT, YOU CAN STILL CONTRIBUTE TO A HEALTH SAVINGS ACCOUNT.

BUT IF YOU DON'T HAVE A HEALTH SAVINGS ACCOUNT OR YOU DON'T HAVE EMPLOYER HEALTH, YOU SHOULD BE SIGNING UP AT AGE 65 FOR THAT.

NOW PART A, WHAT WE ARE REALLY TALKING ABOUT AND THAT COVERS INPATIENTS.

AND IT DOESN'T MATTER WHETHER YOU ARE AN INPATIENT IN A HOSPITAL, WHICH IS WHAT MOST PEOPLE THINK OF, OR A SKILLED NURSING FACILITY, REHAB FACILITY AND ALL OF THAT IS REALLY PAID FOR BY GENERAL TAXES THAT IS DEVELOPED THROUGH THE U.S.

SO THAT MOST PEOPLE DON'T HAVE A PREMIUM.

THERE ARE A VERY SMALL NUMBER OF PEOPLE THAT CAN BUY INTO MEDICARE PART A IF THEY DIDN'T HAVE THE 40 QUARTER WORK EFFORT THROUGH SOCIAL SECURITY.

THERE IS A CO-PAY FOR EVERY ADMISSION THAT YOU HAVE BUT OTHERWISE THERE IS NO CHARGE FOR PART A.

>> SO LET'S CONTINUE THROUGH THE ALPHABET THAT IS MEDICARE.

I THINK IT'S CONVENIENT OF SOMEONE TO GO A, B, C AND D OWE LET'S START OFF WHAT IS MEDICARE PART B.

>> PART B IS OUTPATIENT.

PART A WAS INPATIENT, PART B IS OUTPATIENT WHETHER YOU ARE GETTING A PROCEDURE AT THE OUTPATIENT HOSPITAL OR AMBULATORY SERVICE CENTER OR IN YOUR DOCTOR'S OFFICE CHT IT COVERS PHYSICIAN FEES, SOME DRUGS AND VACCINES, ESPECIALLY THE DRUGS GIVEN BY INFUSION AS AN OUTPATIENT OR EVEN IN YOUR PHYSICIAN OFFICE.

DURABLE MEDICAL EQUIPMENT.

AND SOME OTHER PREVENTATIVE THINGS.

NOW THAT HAS A MONTHLY PREMIUM FOR PART B.

AND IT'S TAKEN OUT, FOR MOST PEOPLE, OUT OF THEIR SOCIAL SECURITY PAYMENTS BUT IF THEY'RE NOT ON SOCIAL SECURITY YET, THEN YOU HAVE TO PAY IT DIRECTLY TO MEDICARE.

NOW IN ADDITION TO THAT, SOME ARE FORTUNATE ENOUGH TO HAVE WHAT IS CALLED AN IRMA, INCOME RELATED MONTHLY ADJUSTED AMOUNT.

AND IF YOUR INCOME IS HIGH ENOUGH, THEY START CHARGING YOU MORE MONEY.

AND THAT'S ADDED TO THE BASE AMOUNT FOR BOTH PART B AND PART D, WHICH WE'LL GET TO IN A LITTLE BIT.

NOW PART B PREMIUMS ARE SET UP SO THAT 25% OF THE ESTIMATED COST OF THE WHOLE PROGRAM FOR THE YEAR IS GOING TO BE CHARGED TO THE PREMIUMS.

BUT IF YOU ARE MAKING A LOT OF MONEY, THEY UP THAT ANTE SO THAT THE HIGHEST LEVEL YOU ARE PAYING 85% OF YOUR EXPECTED COSTS OF IT.

>> I THINK A LOT OF US THINK THAT ONCE I GET ON TO MEDICARE, I'M THROUGH PLAYING HEALTH INSURANCE PREMIUMS BUT WHAT YOU HAVE SAID IS NO, YOU ARE STILL MAKING A PAYMENT EVEN THOUGH YOU ARE ON A RETIRED INCOME.

>> CORRECT.

AND A LOT OF IT IS COMING OUT OF YOUR SOCIAL SECURITY CHECT OR RAILROAD RETIREMENT CHECK SO THAT YOU DON'T REALLY SEE IT.

>> BUT YOU DO FEEL IT.

>> YES.

>> NOW, TELL ME ABOUT PART C AND HOW THIS DIFFERS.

>> PART C IS BASICALLY CALLED, BY MOST PEOPLE, MEDICARE ADVANTAGE PROGRAMS.

SOME PEOPLE WILL REFER TO IT AS A WAIVER PROGRAM BECAUSE YOU ARE WAIVING TRADITIONAL MEDICARE AND YOU ARE GOING TO RECEIVE ALL YOUR BENEFITS THROUGH YOUR NEW MEDICARE ADVANTAGE PROGRAM.

THEY COVER YOUR PARTS A YOUR INPATIENT, PART B OUTPATIENT AND PART D, DRUGS, PHYSICIANS AND EVERYTHING ELSE.

NOW YOU STILL HAVE TO CONTINUE TO PAY YOUR PART B PREMIUM TO MEDICARE EITHER DIRECTLY OR THROUGH YOUR SOCIAL SECURITY DEDUCTION.

AND YOU MAY STILL HAVE THAT IRMA THAT HAVE YOU TO PAY DIRECTLY TO MEDICARE IF YOU ARE MAKING ENOUGH MONEY.

NOW THESE MEDICARE ADVANTAGE PROGRAMS MAY OR MAY NOT HAVE AN ADDITIONAL PREMIUM.

BUT A LOT OF THEM PROVIDE ADDITIONAL SERVICES.

THEY HAVE SOME VISION COVERAGE, SOME OF THEM GLASSES, CONTACTS, DENTAL COVERAGE, HEALTH CLUB MEMBERSHIPS AND THINGS LIKE THAT SO THERE ARE SOME DIFFERENCES BETWEEN THEM.

>> WE ARE GOING TO COME BACK AND TALK ABOUT THE DIFFERENCE BETWEEN THE MANAGED CARE SIDE OF THIS AND THE STANDARD IN A MOMENT BUT FIRST TELL ME ABOUT PART D. THIS IS A CONFUSING ONE FOR MANY OF US.

>> PART D IS THE ONE THAT COVERS PRESCRIPTION DRUGS COVERAGE AND THERE HAVE BEEN SOME CHANGES OVER THE PAST SEVERAL YEARS.

AND IT IS A SEPARATE MONTHLY PREMIUM THAT YOU HAVE TO PAY TO A COMPANY.

IT'S RUN BY THE PRIVATE COMPANIES AND THEY MAY CHANGE AND DIFFER IN THE DRUGS THAT THEY COVER.

AND THOSE DRUGS MAY CHANGE YEAR TO YEAR.

NOW THEY MAY ALSO, AS I SAID EARLIER, HAVE THE IRMA WHERE YOU ARE MAKING A LOT OF MONEY, YOU PAY ADDITIONAL BUT THAT GOES TO MEDICARE.

THE BIGGEST CHANGE WHICH MAY BE CONFUSING AND AT THE SAME TIME SIMPLIFYING SOME THINGS IS THAT FOR 2025, THE MAXIMUM OUT OF POCKET WILL BE $2,000 FOR DRUGS.

NOW WHAT THAT MEANS IS THAT IT IS A CAP ON THE DRUG COSTS.

YOUR PREMIUMS DON'T COUNT TOWARD THAT CAP AT ALL.

DRUGS THAT YOU DON'T BUY THROUGH THE PLAN DON'T COUNT SO IF YOU BUY SOMETHING OVER THE COUNTER OR IF YOU FIND THAT THE GOOD RX AND THERE ARE SEVERAL OTHER DIFFERENT DISCOUNT CARDS THAT YOU CAN HAVE, IF YOU BUY IT THROUGH THAT, BECAUSE IT COSTS YOU LESS, THOSE COSTS DON'T APPLY TO THE 2000-DOLLAR MAX.

THERE ARE FREE VACCINES THAT ARE PART OF PART D, RSV, SHINGLES, D.P.T.

VACCINES, THOSE ARE PROVIDED FREE AND BECAUSE THEY'RE PROVIDED FREE TO YOU, THOSE DON'T COUNT TOWARDS THAT $2,000 CAP EITHER.

THERE ARE OTHER VACCINES YOU GET, YOUR FLU SHOT, HELP HEPATITIS B AND THOSE ARE PART D. THEY DON'T COUNT TOWARD THE PART B.

IT'S CONFUSING ON THE VACCINES WHICH PART IS COVERED BY WHAT.

LET'S NOT GET INTO THAT.

>> ARE YOU SUGGESTING WE SHOULD JUST ACCEPT THE FACT THAT WE ARE GETTING THIS SORT OF THING.

>> WE DON'T MAKE THE RULES.

WE JUST HAVE TO FOLLOW THEM.

>> ALL RIGHT.

SO MEDICARE ADVANTAGE AROUND OCTOBER TO MID DECEMBER, WE GET PHONE CALLS FROM JOE NAMATH AND OTHER CELEBRITIES AND OTHER PEOPLE TELLING US, I WANT YOU TO SIGN UP WITH MY PLAN.

YOU JUST SAID THAT I'M NOT GOING TO PAY ANYMORE, BUT THEY'RE TELLING ME I'M GETTING ALL THESE WONDERFUL SERVICES.

IF I'VE LEARNED ANYTHING IN LIFE, THERE IS NO FREE LUNCH.

>> THAT'S CORRECT.

>> WHY WOULD YOU WANT MEDICARE ADVANTAGE VERSUS STANDARD MEDICARE?

>> MEDICARE ADVANTAGE DOES OFFER FREQUENTLY ADDITIONAL BENEFITS TO THE PERSON WHO SIGNS UP FOR THEM.

I MENTIONED THEM EARLIER.

VISION COVERAGE THAT REALLY IS VERY, VERY LIMITED ON TRADITIONAL MEDICARE.

DENTAL COVERAGE, AGAIN, VERY LIMITED ON TRADITIONAL MEDICARE.

HEALTH CLUB, YOU CAN GO TO SILVER SNEAKERS IS ONE OF THE MORE POPULAR ONES WITH A LOT OF THEM SO THAT YOU CAN HAVE MEMBERSHIP AT A Y OR THINGS LIKE THAT.

>> SURE.

>> SO THERE ARE SOME BENEFITS THERE.

AND SOME OF THEM, IN SOME MARKETS, DO CHARGE A MONTHLY PREMIUM.

NOW, A LOT OF THIS ADVERTISING IS BECAUSE THE COMPANYIES PAY A PREMIUM FOR EVERY HEAD THESE COMPANIES CAN SIGN UP WITH THE MEDICARE ADVANTAGE PROGRAM.

SO THE REASON THAT MID OCTOBER TO DECEMBER 7 IS OPEN SEASON ON SENIORS IS THEY WANT YOU TO SWITCH PLANS TO WHATEVER THEY ARE PROMOTING.

AND THAT'S WHY THERE IS NO CHARGE FOR YOU TO TALK TO THEM.

BUT IF YOU TALK TO TWO OR THREE OF THEM, YOU WILL FIND YOU GET A LOT OF PHONE CALLS IN A HURRY.

>> IT'S INTERESTING THE TERM OPEN SEASON.

ALL I CAN IMAGINE IS ELMER FUDD OPEN SEASONING DUCK HUNTING.

THAT'S WHAT I FEEL LIKE, A DUCK IN A BARREL AND EVERYBODY AND THEIR BROTHER... >> THAT'S RIGHT.

>> BUT THERE IS SOMETHING THAT IS INTERESTING ABOUT THIS, TO ME, AND THAT IS MEDICARE PAYS ONE THING.

BUT THE FEDERAL GOVERNMENT IS PAYING AN EXTRA AMOUNT OF MONEY FOR MEDICARE ADVANTAGE, AREN'T THEY?

>> MRK ADVANTAGE PROGRAM-- MEDICARE ADVANTAGE PROGRAMS GET MONEY EVERY MONTH FROM THE FEDERAL GOVERNMENT TO RUN THEIR PROGRAMS BUT THERE IS ALSO ADDITIONAL BONUSES, PREMIUMS THAT THE COMPANIES GET IF THE CERTAIN METRICS ARE MET.

THEY WORK VERY HARD TO GET THOSE.

ONCE YOU ADD UP ALL OF THOSE DIFFERENT ITEMS, IT TURNS OUT THAT THE MEDICARE ADVANTAGE PROGRAMS COST USUALLY 15, SOMETIMES UP TO 20% MORE THAN WHAT IT COSTS THE FEDERAL GOVERNMENT FOR A PERSON TO BE IN TRADITIONAL MEDICARE.

WHICH IS VERY SURPRISING FOR A LOT OF PEOPLE BECAUSE THE FEDS ARE TRYING TO PUSH MEDICARE ADVANTAGE PROGRAMS AND NOW OVER HALF OF MEDICARE BENEFICIARIES ARE IN ONE OF THESE MEDICARE ADVANTAGE PAMS PROGRAMS.

>> WHAT IS THE BIGGEST MISCONCEPTION THAT'S PATIENTS HAVE ABOUT BEING IN STANDARD MEDICARE VERSUS MEDICARE ADVANTAGE?

SAY FOR INSTANCE PORTABILITY.

>> MOST PEOPLE THINK MEDICARE HAS COVERAGE EVERYWHERE.

THAT'S NOT EXACTLY TRUE.

EVEN WITH TRADITIONAL MEDICARE, YOU DO NOT HAVE COVERAGE WITH RARE EXCEPTIONS OUTSIDE OF THE UNITED STATES.

SO IF YOU ARE TAKING A TRIP ABROAD, YOU BETTER BUY A TRAVEL INSURANCE PLAN OR HAVE SOME OTHER THINGS IN ORDER BECAUSE MEDICARE WILL NOT COVER THINGS OUTSIDE OF THE UNITED STATES AND ITS POSSESSIONS.

MEDICARE ADVANTAGE PROGRAMS RARELY WILL HAVE SOME OF THE COVERAGE BUT ONE OF THE BIGGER THINGS IS THAT IF YOU GO OUT OF YOUR HOME AREA, WHERE THE PLAN IS BASED, YOU PROBABLY HAVE VERY LIMITED COVERAGE AND YOU WILL HAVE SOME EMERGENCY COVERAGE SO IF YOU SHOW UP FROM A CAR ACCIDENT OR HEART ATTACK IN A HOSPITAL, YOU'VE GOT SOME COVERAGE THERE.

BUT IT'S NOT GOING TO BE THE SAME AS IN YOUR HOME AREA.

SO PEOPLE THAT TRAVEL AROUND A LOT DON'T NECESSARILY WANT TO BE IN AN M.A.

PLAN AND I PERSONALLY AM IN TRADITIONAL MEDICARE BECAUSE I HAVE FAMILY IN ATLANTA IN THE CITY, NORTH OF SEATTLE AND THERE IS NO MEDICARE ADVANTAGE PROGRAM THAT IS STRONG IN ALL THOSE AREAS PLUS MY HOME.

>> SOUNDS LIKE YOUR FAMILY IS TRYING TO RUN AWAY FROM YOU BUT YOU ARE NOT GOING TO LET THEM GET AWAY.

I LIKE YOUR TENACITY.

THERE IS SOMETHING ELSE TO IT.

I THINK THERE IS AN INSIDIOUS SIDE TO THIS OR MAYBE IT'S JUST MY PERCEPTION IS WRONG.

DENIALS OF CARE.

THIS IS SOMETHING THAT IS REALLY OUT THERE.

IT SEEMS LIKE IS IT HIGHER WITH THE MEDICARE ADVANTAGE PLANS THAN IT IS THROUGH TRADITIONAL MEDICARE OR HOW DOES THAT WORK?

>> TRADITIONAL MEDICARE HAS VERY FEW PRIOR AUTHORIZATION REQUIREMENTS.

AND THEY DO DENY SOME CARE ON THE BACK END WHEN THEY DO AUDITS AND FIND THAT SOMETHING DOESN'T REALLY MAKE SENSE: THAT'S NOT VERY COMMON.

MEDICARE ADVANTAGE PROGRAMS HAVE LITERALLY EXPLODED WITH THE NUMBER OF PRIOR AUTHORIZATIONS THAT ARE REQUIRING.

ESPECIALLY IN THE PAST TWO YEARS.

AND THEY'RE NOW DENYING A LOT OF THOSE PRIOR AUTHORIZATIONS.

UNITED HEALTHCARE RECENTLY, IT HAS BEEN FOUND OR PROMULGATED THEY ARE DENYING 32% OF ALL OF THEIR PRIOR AUTHORIZATIONS.

>> 32%.

>> 32%.

>> WOW.

>> IT IS REPORTED THAT THEY HAVE BEEN USE USING ARTIFICIAL INTELLIGENCE TO GENERATE THE DENIALS RATHER THAN SOMEBODY REALLY LOOKING AT IT AND SAYING THIS MAKES SENSE.

THEY'RE JUST DENYING IT.

ON THE BACK END, THE TIME INTENSE PROBLEM IS THAT NOW THE PHYSICIANS, THE PROVIDERS AND THEIR OFFICES HAVE TO CONTACT THE INSURANCE COMPANIES, ASK FOR APPEALS.

FREQUENTLY IT'S A PEER-TO-PEER, WHICH IS WHERE THE DOCTOR HAS TO TALK TO ONE OF THEIR DOCTORS DIRECTLY.

84% OF THE TIME THOSE DENIALS ARE OVERTURNED ON APPEALS.

WHICH MEANS IT'S A HUGE BURDEN ON THE PHYSICIAN THAT WE ARE DOING AND WE DON'T GET PAID FOR THAT.

IT JUST EATS TIME.

>> TO BE FAIR TO UNITED HEALTHCARE, THIS IS HAPPENING THOUGH WITH OTHER INSURERS ALSO.

>> IT'S HAPPENING ALL OF THE MEDICARE ADVANTAGE PROGRAMS HAVE INCREASED THEIR PRIOR AUTHORIZATION.

THE NUMBER WITH THE UNITED HEALTHCARE IS THAT THEY'RE FAR AND AWAY DENYING TWICE THE RATE OF EVERYBODY ELSE.

>> GOTCH ARC.

GOTCHA.

WE RECENTLY HAD AN ELECTION AND THERE IS GOING TO BE A CHANGE IN HEALTH POLICY, AT LEAST FROM THOSE WHO HAVE BEEN PROPOSED TO HEAD CMS AND ALSO THE DEPARTMENT OF HEALTH AND HUMAN SERVICES.

WHAT DOES THAT LOOK LIKE FOR US AS FAR AS MEDICARE ISSUES ARE CONCERNED?

>> FIRST OF ALL, WE HAVE YET TO SEE WHEN THIS IS BEING TAPED WHO IS GOING TO BE CONFIRMED BY THE SENATE FOR THESE POSITIONS.

IF YOU TAKE A LOOK AT WHAT Dr. OZ HAS PROPOSED.

HE IS PROPOSED TO BE HEAD OF CMS, CENTERS FOR MEDICARE AND MEDICAID SERVICES WHO RUNS MEDICARE AND MEDICAID.

HE HAS LIKED M.A.

PLANS AND PUSHED THEM AND PROMOTED THEM IN THE PAST SO HE IS PROBABLY GOING TO TRY TO MAKE SOME CHANGES BUT HE IS ALSO NEEDING TO DEAL WITH THE FACT THAT THEY'RE COSTING ANOTHER 15% ON TOP OF WHAT REGULAR MEDICARE DOES.

AND IF THERE IS A PUSH TO TRY TO RESTRAIN THE EXPENDITURES IN MEDICARE, YOU ARE GOING TO HAVE TO DEAL WITH THAT.

NOW RFK, JR. WHO IS HEAD OF HEALTH AND HUMAN SERVICES, THAT IS OVER ARCHING ABOVE CMS.

HE REALLY PUSHES PREVENTION MORE THAN JUST TREATMENT, WHICH IS VERY GOOD.

BUT ONE OF THE ISSUES IS THAT MEDICARE, THE WAY IT WAS SET UP, IS TO TREAT DISEASE AND CHRONIC CONDITIONS.

SO THAT IT MAY TAKE LEGISLATIVE ACTION FOR IT TO EXPAND INTO MORE PREVENTION.

EVERY EXPANSION TOWARDS SCREENING, WHETHER YOU ARE TALKING ABOUT MAMMOGRAMS, WHETHER YOU ARE TALKING ABOUT PSA CHECKS, ANYTHING, ANY OF THOSE SCREENINGS, HAD TO HAVE LEGISLATIVE ACTION BECAUSE THE ORIGINAL MEDICARE DOESN'T COVER THAT.

SO I THINK Dr. OZ AND Mr. KENNEDY MAY RUN INTO SOME HEAD WINDS THAT WE REALLY DO NEED TO HAVE LEGISLATIVE ACTION ON THAT.

EXACTLY WHAT HAPPENS, NOT SURE.

I KNOW THAT RFK, JR.

DOESN'T LIKE THE CURRENT PAYMENT PLAN THAT WE HAVE.

SO IT WILL BE INTERESTING TO SEE HOW THAT CHANGES.

>> BUT PUTTING MORE EFFORT INTO PREVENTATIVE HEALTH SERVICES HAS GOT TO BE A BOON TO OWR INDIVIDUAL HEALTH AND WOULDN'T IT SAVE MONEY DOWN THE ROAD?

>> THAT'S AN INTERESTING CONUNDRUM.

YES, PREVENTION SHOULD SAVE ME AND YOU AS AN INDIVIDUAL GRIEF DOWN THE ROAD BECAUSE WE CAN PICK UP THINGS EARLY AND IT DOESN'T MATTER WHAT YOU ARE TALKING ABOUT.

IF YOU START FIXING A PROBLEM EARLY, IT TAKES A WHOLE LOT LESS EFFORT, A WHOLE LOT LESS MONEY AND A WHOLE LOT LESS GRIEF THAN WAITING UNTIL IT BECOMES A MUCH BIGGER DISASTER.

NOW, IS IT GOING TO SAVE MONEY?

YES AND NO.

FOR AN INDIVIDUAL, IT WILL SAVE MONEY.

BUT IF YOU ARE TALKING ABOUT THE POPULATION AS A WHOLE, IT IS GOING TO PROBABLY INCREASE COSTS BECAUSE WE HAVE THOSE PEOPLE ALIVE LONGER AND MOST OF THOSE PEOPLE IN MEDICARE, THEY'RE NOT WORKING, THEY'RE NOT PAYING NEARLY AS MUCH TAXES.

SO THAT AS THE POPULATION GROWS, THE HEALTH EXPENDITURES GROW.

>> SO EVEN THOUGH WE ARE SPENDING IT ON PREVENTATIVE SERVICES, WE ARE STILL SPENDING THE MONEY.

BUT LET'S SAY IF SOMEONE IS LOOKING FOR, IN YOUR FIELD, AN ANEURYSMS AND WE KNOW WE CAN DO WHAT, AN ULTRASOUND OR C.T.

SCAN LOOKING FOR THIS, THAT KEEPS A PERSON ALIVE BUT ON THE OTHER HAND YOU ARE SAYING THAT WE ARE ALSO, BECAUSE THEY'RE GOING TO BE ALIVE, THEY'RE GOING TO BE DOING MORE TESTING AND OTHER TREATMENTS, OTHER FIXES AND PATCHES ALONG THE WAY.

>> CORRECT.

AND THE OLDER PEOPLE GET, AND THE MORE CONDITIONS THEY HAVE HAD DURING THEIR LIFE, THE HARDER IT IS TO FIX THE NEXT PROBLEM.

>> ARE WE SAVING MONEY.

>> IT DEPENDS ON HOW ITS DONE.

THE WAY THAT WE TAKE A LOOK AT THINGS IN THE U.S. IS IT'S AN INDIVIDUAL.

YOU TAKE A LOOK AT EUROPEANS THEY DO IT MORE ON A POPULATION BASIS.

>> EXPLAIN THE DIFFERENCE.

>> THE DIFFERENCE IS THAT IF I'M LOOKING AT YOU TODAY, IN THE U.S., I TREAT YOU AS A PATIENT.

YOUR HEALTH IS THE NUMBER ONE CONCERN.

IF YOU TAKE A LOOK AT WHAT HAPPENS IN THE DANISH SYSTEM, THEY'RE GOING TO SAY I'M SORRY, YOU ARE OLD.

WE ARE NOT GOING TO DO THIS UNLESS YOU HAVE HAD A PRIOR STROKE.

BECAUSE THEY WANTED TO HOLD DOWN COSTS.

HUGE DIFFERENCE.

>> WHEN WE LOOK AT THE STATUS OF HEALTH OF THESE MANY OF THESE EUROPEAN COUNTRIES WHERE THEY'RE DOING THAT, THEY TEND TO BE BETTER THAN US.

>> IF YOU TAKE A LOOK AT THE VIOLENCE THAT WE HAVE THE DRUG ABUSE THAT WE HAVE HAD, THE DEATHS THAT COME FROM THOSE ISSUES AND THE FACT THAT IT AFFECTS THE YOUNGER PEOPLE, THAT REALLY SKEWS SOME OF THE LONGEVITY SO IF YOU REMOVE THOSE, ALL OF A SUDDEN WE ARE RIGHT BACK IN THE BALL GAME.

>> I HAVE OFTEN HEARD THAT YOU LOOK AT THE POPULATION UP TO AGE 65 WE DID WORSE BUT FROM 65 AND ABOVE WHEN PEOPLE HAD MEDICARE, OUR HEALTH STATUS NOW WE ARE RANKED ONE OR TWO IN THE WORLD AS OPPOSED TO 36 OR WHATEVER.

>> BY THE TIME YOU ARE 65, YOU HAVE MOST PEOPLE ARE NOT SHOOTING EACH OTHER OR DRIVING DRUNK, NOT DOING THESE THING THAT HAVE TAKEN OUT A LOT OF OUR POPULATION AT A YOUNGER AGE.

>> FROM THE PHYSICIAN AND HOSPITAL PERSPECTIVE, ARE MANY OF YOUR COLLEAGUES?

ARE WE HAPPY WITH THE MEDICARE?

>> ABSOLUTELY NOT.

PEOPLE THINK THE TAX CODE IS COMPLEX, IT HAS WELL OVER 100,000 PAGES OF REGULATIONS.

MEDICARE UNDERSTAND AND MEDICARE HAS WELL OVER 300,000 PAGES OF REGULATIONS.

AND WHAT HAS HAPPEN IS THE COST OF PRACTICE HAS GONE UP AND THE PHYSICIAN FEE SCHEDULE HAS GONE NOWHERE.

AND IN MANY CASES, SIGNIFICANTLY DOWN F. YOU TAKE A LOOK AT WHAT MEDICARE ADMITS, ADJUSTED FOR INFLATION FROM 2,000 TO 2021, THE HOSPITALS AND THE SKILLED NURSING FACILITIES GET MORE MONEY, THEIR COSTS ARE GOING UP OR THEIR REIMBURSEMENT IS GOING UP HIGHER THAN THE CONSUMER PRICE INDEX, HIGHER THAN MEDICAL INFLATION.

BUT YOU LOOK AT THE PHYSICIANS AND WE ARE UP 10% WHICH IS ONLY A TINY FRACTION OF WHAT INFLATION HAS BEEN.

SO THIS IS ONE OF THE DRIVING FORCES FOR A LOT OF THE PHYSICIANS HAVING TO SELL OUT AND BE BOUGHT OUT BY HOSPITALS OR VENTURE CAM FIRMS BECAUSE THEY SIMPLY CAN'T KEEP THEIR DOORS OPEN.

VIRTUALLY NOBODY IS COMING OUT OF MEDICAL SCHOOL OR RESIDENCY AND GOING INTO PRIVATE PRACTICE ANYMORE SIMPLY BECAUSE THEY CAN'T AFFORD IT.

AND SO IT HAS FORCED PEOPLE INTO WORKING FOR THE HOSPITAL AND THEY PAY THE HOSPITAL MORE SO THE EXACT SAME TEST THAT WE WOULD DO IN OUR OFFICE AS PRIVATE PHYSICIANS MAY COST TWICE AS MUCH IN THE HOSPITAL.

AND THE HOSPITAL IS MAKING MONEY AND THAT'S HOW THEY CAN AFFORD TO HIRE THE DOCTORS.

>> SIMPLE ANSWER.

IS MEDICARE GOING TO BE HERE FOR ANOTHER COUPLE OF YEARS?

>> ABSOLUTELY.

>> THAT'S A GOOD THING.

>> IT'S A GOOD THING THE POLITICIANS WILL NOT LET IT DIE BECAUSE IF THEY DO, THEY'RE GOING TO BE VOTED OUT OF OFFICE.

>> Dr. MARTIN, KEVIN, THANK YOU VERY MUCH FOR BEING WITH US.

AND I'M LOOKING FORWARD TO TALKING TO YOU WITH MEDICAID ON THE NEXT SHOW.

AND THANK YOU FOR BEING WITH US TODAY.

I THINK YOU SEE THAT MEDICARE HAS PROVEN TO BE A SIGNIFICANT BENEFIT TO THE HEALTH OF OLDER AMERICANS.

YOU KNOW, WE CAN ALL USE A LITTLE BIT OF HAND HOLDING TO NAVIGATE AROUND THE VARIOUS PLANS, OPTIONS, COVERAGES AND DEADLINES.

LIKE MOST THINGS, SEEK OUT SEVERAL OPINIONS AND CHOOSE THE OPENING OPTIONSES THAT MOST FIT YOUR NEEDS AND POCKETBOOK.

JOIN US NEXT WEEK WHEN WE WILL HAVE PART 2 OF OUR DISCUSSION WHEN WE TALK ABOUT MEDICAID.

IF YOU WISH TO WATCH THIS SHOW AGAIN OR ARCHIVED VERSION OF PAST SHOWS PLEASE GO TO ket.org.

AND IF HAVE YOU A QUESTION OR COMMENT ABOUT THIS OR OTHER SHOWS, WE CAN BE REACHED ADD KY HEALTH@ket.org.

LOOK FORWARD TO SEEING YOU NEXT WEEK AND BE HERE WHEN WE TALK ABOUT MEDICAID.

>> "KENTUCKY HEALTH" IS FUNDED IN PART BY A GRANT FROM THE FOUNDATION FOR FOR A HEALTHY KENTUCKY.

♪ ♪