This month’s newsletter reveals the soft underbelly of Medicare Advantage plans and how they compare to original Medicare and a Medigap plan.

We also touch on the growing need for memory care workers and how it may impact you.

In case you missed it, AI (artificial intelligence) is rapidly invading almost all aspects of health care. Those tablets used by doctors and other medical personnel are like miniature brains that are supposed to aid in diagnosis and treatment. But how accurate are the results, and who is responsible for an incorrect diagnosis?

The 20% Problem with Medicare Advantage Plans

Imagine a plan where you only pay 20% of the cost of healthcare. Sounds like a deal, right? Buyer beware!

Not all services are covered by the Advantage copay. Many outpatient services require the patient to pay 20% of the approved cost of care. Here is a partial list of things where you may be required to pay 20% . . .

Chemotherapy

Radiation therapy

Infusion therapy

Part B medications

Ambulance, including air ambulance

Outpatient surgery including cataracts

Dialysis

PT (physical therapy)

SNF (skilled nursing facility) and rehab services following a hospital stay

Memory care for Alzheimer’s and dementia patients

DME (durable medical equipment) including walker, wheelchair, hospital bed, CPAP, oxygen, home infusion services, nebulizer and medication for nebulizer, etc.

You are responsible for your 20% share UP TO the plan maximum, typically $5,000 to $8,500 for PPO plans . . . could be up to $12,000 in some cases.

Ouch!

Original Medicare, no networks, no referrals, no prior authorization delays paired with the G Medicare supplement plan. The G plan pays 20% for you!

Your OOP for covered Part B medical expenses is the Part B deductible ($240 in 2024.

20% up to $5,000+ or $240?

Case closed!

The memory care sector will require one million new direct care workers by 2031, a need greater than in any other occupation in the U.S.

That’s according to the latest Alzheimer’s Association 2024 Facts and Findings report, released earlier this month. The annual report details national and state statistics related to Alzheimer’s prevalence, mortality, cost of care and caregiving.

According to the report, between 2012 and 2021, the number of direct care workers increased from 3.2 million to 4.8 million. But more than 1 million additional direct care workers are needed between 2021 and 2031 to meet future care demands, according to the report.

https://seniorhousingnews.com/2024/03/27/memory-care-sector-needs-1-million-more-direct-care-workers-by-2031/

Medicare will pay for some, but not all, care costs.  Learn about Medicare memory care for Alzheimer's and other dementia care.

https://www.alz.org/help-support/caregiving/financial-legal-planning/medicare

AI and Healthcare in the News

NOTE: Many of the articles linked below address the issue of using managed care (PPO and HMO Advantage plans) as  “artificial intelligence” is rapidly invading almost every aspect of our lives. 

Many of the robocalls pitching anything from extended warranty to burial plots use AI generated voices to create the semblance of a real person. Neither Elvis nor the president are on the other end of the line. You are talking to a robot, similar to “Alexa”.

Original Medicare does not use AI to adjudicate claims. Neither do the Medigap carriers, because there is no adjudication at the secondary level.

But AI is infiltrating almost every other level of healthcare as you will discover when you read the snippets below.

The Dearth of Human Touch and Empathy:

Medicine is as much an art as it is a science, rooted in the human connection between caregivers and patients. One of the most glaring limitations of AI in healthcare is its inability to understand and engage with patients on an emotional level. The limitations of AI in healthcare, including its lack of intuition and empathy, underpin the most fundamental aspect of caregiving. This often leaves patients wanting the personal touch that only a human can provide.

Despite the ever-increasing sophistication of AI models, a black box phenomenon still pervades the technology. When an AI system delivers a diagnosis or treatment recommendation, it often cannot explain why it reached that conclusion. Healthcare professionals require interpretability to trust and understand the reasoning behind AI’s decisions, particularly when human lives are at stake.

https://medium.com/@jamesadamm1947/what-are-the-limitations-of-ai-in-healthcare-8906e806ba9e

Why You May Not Want AI Determining Your Post-Acute Care

The Centers for Medicare & Medicaid Services (CMS) is placing limits on the use of artificial intelligence (AI) tools in denials of claims related to Medicare Advantage plans, and adding more guidance to health care providers on post-acute care admissions.

“An algorithm or software tool can be used to assist providers or MA plans in predicting a potential length of stay, but that prediction alone cannot be used as the basis to terminate post-acute care services,” according to the CMS FAQ.

https://skillednursingnews.com/2024/02/cms-medicare-advantage-plans-can-use-ai-tools-to-assist-but-not-terminate-post-acute-care-stays/

Patients Have Concerns as Well

Although AI has demonstrated that it is as accurate in diagnosing conditions or recommending treatment protocols, 60% of Americans said they would be uncomfortable if their healthcare provider relied on AI to diagnose conditions or recommend treatments, according to a Pew Research Center poll.

https://www.thomsonreuters.com/en-us/posts/technology/ai-usage-healthcare/

The Downside of AI in Healthcare

Who is responsible for AI-related mistakes? How and should AI handle end-of-life decisions? How do we ensure that AI does not perpetuate healthcare disparities or demographic biases?

While AI systems can be highly accurate, they are not infallible. There is always a risk of misdiagnosis or overlooking crucial information, leading to potentially life-threatening errors. The "black-box" nature of some of these AI systems can also make it challenging to understand the basis for their decisions or where responsibility lies in the event of these errors.

Decisions made by AI assisted software are only as good as the humans who input the symptoms and physical observations.

https://www.forbes.com/sites/forbesbusinesscouncil/2023/12/01/balancing-the-pros-and-cons-of-ai-in-healthcare/?sh=7af43667752b

Not All Doctors are On Board with AI

Among the key findings, the physician survey showed:

The potential for health care AI has 41% of physicians equally excited and concerned.

Enthusiasm was highest for AI tools that help reduce administrative burdens, including documentation (54%) and prior authorization (48%).

AI tools were most helpful for enhancing diagnostic ability (72%)

Concern was highest for AI tools that impact the patient-physicians relationship (39%) and patient privacy (41%).

The top attributes required to advance physician adoption of AI tools were data privacy assurances (87%) and not being held liable for AI model errors (87%).

Transparency is key for AI tools with about 80% of physicians indicated they want clear information about key characteristics and features regarding the design, development, and deployment of AI tools.

https://www.ama-assn.org/press-center/press-releases/ama-physicians-enthusiastic-cautious-about-health-care-ai

Hopefully you learned something with this newsletter. That is the goal of all my letters, to offer information in such a way as to enlighten and educate.

Feel free to pass this along to friends and relatives. Call or email with questions and referrals are ALWAYS appreciated.

Take care,

bob