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The Disadvantages of the Medicare Advantage Plan

Rheumatoid arthritis is one of the most crippling forms of arthritis. It affects approximately three million patients in the United States every year and primarily strikes a person at their most productive time of life. The onset can be rapid with deterioration from full functional status to being bedridden within two weeks. In addition to the joint damage and pain, the loss of independence and the need for assistance can be devastating to the patient and their family.

Prior to 1998, the treatments for rheumatoid arthritis were archaic and ineffective. Patients slowly deteriorated over a five to 10 year period until they required walkers, canes or possibly wheelchairs. In 1998, new therapies were approved for the treatment of rheumatoid arthritis. These therapies fell under the general category of Biologics, and were either injections or infusions. Finally, rheumatoid arthritis could be brought under control and prevention of damage was possible. For many patients, these infusions were the answer to their prayers and were the key to remaining productive and independent.

For the patient who had traditional Medicare coverage, their insurance would cover 80% of the cost the infusion under Part B. A patient could also purchase a secondary insurance policy to cover the remaining 20% not covered under traditional Medicare. The infusions usually occurred every six to eight weeks and the patient was assured of continued relief and independence because their insurance policies covered the treatments.

In 2006, the Medicare Advantage program was launched. This program was designed by the Federal government to reduce Medicare costs. In many cases, the patient was told by their insurance agent that the Medicare Advantage policy was “just like” what they had in the past and that it would cover everything. However, the patient was no longer eligible to get the secondary insurance policy to cover remaining expenses.

The lower premium cost of the Medicare Advantage policy was a tremendous enticement for individuals over 65 to abandon the traditional Medicare and secondary insurance coverage. However, for those patients who were on an infusion regime for the treatment of their rheumatoid arthritis, the lack of a secondary policy became an immediate problem. Patients were now faced with a significant bill for their 20% coinsurance.

Pharmaceutical companies sought to assist in this financial gap by funding independent foundations to which a patient could apply for financial assistance. However in the past year, foundation money has not been certain. In the first six months of 2012, 36% of our 58 infusion patients at Piedmont Arthritis Clinic that are covered by Medicare Advantage policies lost foundation support and therefore were unable to receive their treatments. At this time, almost all of the foundations have expended their assets so there is no money available to cover the 20% coinsurance for rheumatoid arthritis patients. This lack of foundation support will continue to impact more and more Medicare Advantage infusion patients as the sources of funding continue to dwindle throughout the year.

As a result of the funding crisis, rheumatoid arthritis patients are being subjected to a break in their infusion therapy and most assuredly will have progression of the disease with permanent damage and possibly deformity. Moreover, we found that if a patient interrupts therapy for more than four months, there is an increased incidence of infusion reactions when the patient’s medication is once again renewed. These reactions have the potential to be life threatening, and certainly prevent the patient from continuing on that drug which in the past had been effective.

While the Medicare Advantage program may indeed be less expensive for a patient with rheumatoid arthritis who requires biologic treatment, patients need to be aware of the severe consequences this choice could have on their health. A decision to go with the lesser financial cost of the premiums could lead to permanent physical deformity when treatment is interrupted. In my opinion, the Medicare Advantage program is actually a disadvantage to patients, and I strongly encourage them to consider the negative consequences joining such a program could bring to their care.

Dr. Lawson is the founding partner of Piedmont Arthritis Clinic and the author of several publications on Rheumatoid Arthritis. Dr. Lawson can be reached at opinions@piedmontarthritis.com.