In 2011, Medicare will require every Medicare Advantage plan to have an annual maximum-out-of-pocket (MOOP). This is good news for 30,000 or so seniors in Tucson whose Advantage plan does not have a MOOP.

A MOOP is a cap on expenses for co-pays and co-insurance, and the maximum limit is expected to be $6,700.  However, CMS (Centers for Medicare and Medicaid) encourages Advantage plans to have lower MOOPs and will reward plans that voluntarily cap members’ expenses at a lower amount, such as $3,400.

A MOOP is important when someone has a chronic illness or multiple hospitalizations during a given year. Co-pays for specialists ($35-$45 for each visit), co-pays for MRIs ($150), and hospitalization at $200 per day, can add up. So Medicare is going to require every Advantage plan to set a cap for its members’ annual co-pays.

Cancer is an illness that requires large co-pays for chemo and radiation treatment (20% of the bill) and can quickly add up to five or even ten thousand dollars.  An Advantage plan with a MOOP of $3,400 means that after the member has paid this amount “out of his own pocket”, he will have no more co-payments or co-insurance for the rest of the year. (Some plans have a MOOP but still require co-pays for doctor visits and labs after the MOOP is met.)

The Medicare Advantage plan with the largest enrollment in Tucson (over 28,000 members) does not have a MOOP. I recently got a call from a woman whose mother-in-law is in this plan and is being treated for breast cancer.  The co-pay for chemotherapy under every Medicare Advantage plan in Tucson is 20% of the bill.   So a person enrolled in a plan with a $3,400 MOOP would have their chemo cost capped at $3,400 through the end of the year.  A person in a plan with a $5,000 MOOP will stop paying at $5,000.  A person in a plan with no MOOP can only wait and see what their total bill will be.  I have heard of people whose 20% co-pay was $10,000.

I have a client who paid $7,000 for radiation treatment for cervical cancer.  That was three years ago.  She told me she charged her payments on her credit card.  She said she is almost finished paying off that credit card bill – three years later.  I cringed when I heard this, realizing she probably paid twice that $7,000 amount with all the interest she incurred over three years.

FOR MORE INFORMATION ON COMPARING MEDICARE ADVANTAGE PLANS, YOU CAN GO TO MEDICARE CHOICES OF ARIZONA.

The World Health Organization rates the French health care system as the best in the world. This conclusion is based on a variety of factors including: low infant mortality rates;  access to care; rates of people cured of treatable diseases; and keeping people healthy and living longer.

• According to the author of “The Healing of America”, France has more doctors and hospital beds per capita than the United States.  On average the French go to the doctor about eight times per year. Five doctor visits per year is the average for Americans.
• French doctors are generally self-employed and medical bills are paid by not-for-profit insurance companies.  People get insurance through their employer if they have a job – but don’t lose it if they are unemployed. French insurance company overhead costs are about 5% of total revenues.  In the U.S., administrative costs for insurance companies (including profits) are generally 20% of revenue.
• France spends about $3,165 per capita on health care and covers every citizen.  The U.S. spends more than $7,000 per capita and has 40 million uninsured citizens.
• France spends about 10% of its GDP on health care while the US spends 17%.
• In France everyone carries their “carte vitale” which contains all their medical records. When a patient sees a doctor, there are no paper files to consult.  The doctor puts “le carte vitale” into his computer and can see the patient’s entire medical history.  The doctor adds his information, clicks a button, and a bill is sent to the insurance company.  Voila! No paperwork to file. No bill to mail. And no confusion over what another doctor might have diagnosed or prescribed.  C’est tres simple.
• French doctors make house calls.
• A consultation with an orthopedic specialist costs $34 in France. The patient pays the doctor and is reimbursed 70% of the cost by his insurance company.  A visit to a specialist in the U.S. generally costs about $400.

I wish I could say the American health care reform law has drawn from the French experience with heath care, but it does not.  The health care reform legislation does promote movement toward computerized records which will reduce costs associated with too much paperwork.

The American system, with hundreds of insurance companies – each with different price schedules and approval  forms – means American medical providers will never be as efficient as their French counterparts.  French hospitals and doctors need very few administrative paper pushers. American hospitals and doctors still need a  team of non-medical staff  to handle insurance forms, prior authorization requests, billing, and denials of payments from insurance companies. This is one part of what makes medical care so expensive in the United States.  C’est dommage.

The big news is that there shouldn’t be big shocks for Medicare Advantage enrollees in November of this year.  And Democrats running for office won’t face the wrath of 11 million seniors – this election year.