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We’re joined by Aniyizhai Annamalai, an internal medicine-psychiatry physician. Dr. Annamalai’s patients are mostly indigent, not employed due to disability, and have serious mental illnesses. Most of them qualify for Medicaid. In this episode, Dr. Annamalai shares her insights on Medicare Advantage plans and how they affect her patients. Despite the aggressive marketing, Medicare Advantage plans offer little benefit for poor and vulnerable patients. Dr. Annamalai shares real-life examples of her patients who were negatively impacted by the switch to a Medicare Advantage plan. Tune in to learn more about the Medicare Advantage debate and how it affects you.

Aniyizhai Annamalai is an internal medicine-psychiatry physician.

She shares her story and discusses her KevinMD article, “Medicare ‘Advantage’ for my indigent patients.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Ani Annamalai. She is an internal medicine-psychiatry physician. Her KevinMD article is titled “Medicare ‘Advantage’ for my indigent patients.” Ani, welcome to the show.

Aniyizhai Annamalai: Thank you. Thank you for having me here, Kevin.

Kevin Pho: So we’ll get into the article a little bit, but first off, briefly share your story and journey to where you are today.

Aniyizhai Annamalai: So I’m an internist and a psychiatrist, as Kevin mentioned. I did a combined internal medicine-psychiatry residency at Southern Illinois University, and I graduated in 2008. Since then, I’ve been here at Yale School of Medicine in New Haven, Connecticut, more specifically practicing at the Connecticut Mental Health Center. I see patients both for psychiatric and medical problems there, so I see a wide range of problems. Plus, the article that I wrote, which I’m going to touch upon today, relates to the insurance that these people get, which I only started realizing and looking into more lately.

Kevin Pho: So let me just ask you about your specialty first. You’re both an internal medicine physician and a psychiatrist. So just in your day-to-day typical workflow, what are some typical medical issues that you would see in patients with behavioral health disease?

Aniyizhai Annamalai: Yeah, so I see patients with very severe mental illness. The people that come to us at CMHC are those with schizophrenia, bipolar disorder, major depression, or substance use; it could be any of those things. But they come with a lot of medical comorbidities, so I see a lot of diabetes, a lot of hypertension, a lot of risk factors for coronary artery disease, and then many things that we see in regular primary care practice, like hypothyroidism, chronic kidney disease, chronic liver disease, etc. And I have to say, I see and practice a lot more diabetes and hypertension in this population than I would in others, because these people don’t easily go for care to other places.

So day to day, I would say in the morning I might be adjusting somebody’s antipsychotic, and in the afternoon I might be treating the diabetes, which could be related to the other treatment that I’m giving them. But it all comes together. So I would say it’s the bread and butter of primary care practice, and the psychiatry is a little bit more skewed toward seeing people with very severe illnesses who really are not able to get care anywhere else. That’s my population.

Kevin Pho: So I’m an internal medicine physician, but I’m not a psychiatrist. So tell me about that influence. For people who have schizophrenia, how does that make it more difficult or more challenging for you to care for the medical issues like diabetes and hypertension?

Aniyizhai Annamalai: Yeah, so there are multiple reasons, and people have written and talked a lot about this. But the fundamental thing is that our health care system, as we know well, is not easy to access, even for the best of us. And these people often need more time, more tolerance, more patience. Even simple things like waiting in a crowded waiting room, or waiting half an hour for their appointment because the doctor is running late, those little things can really throw them off. And also, things like adherence are even more of a problem in this population, and if you treat them as, quote-unquote, “noncompliant,” that doesn’t work as well. You really have to work with the deficiencies and work with the challenges they’re facing.

And also, we talk a lot about social determinants of health, and that’s much more pronounced in this population. Typically, these people have problems with transportation, getting to their appointments, even sometimes having a viable phone number when you make referrals for people to call them. So I would say it’s a lot of problems. And then also, unfortunately, a lot of the treatments that we do have in psychiatry exacerbate some of the underlying medical conditions they have. So with all this, unfortunately, people with mental illness do have an increased mortality. They actually die several years earlier than people who did not have any mental illness. And these are some of the factors, but there are actually many more that we could talk about. It’s difficult to address if you also don’t have that experience and practice seeing these patients on a day-to-day basis. As you know, sometimes it’s very difficult to get access to behavioral health care.

Kevin Pho: Now, what kind of advice or tips do you have for primary care clinicians who see patients for diabetes and hypertension but who also have those comorbidities like schizophrenia, bipolar disorder, or some other mental health illness?

Aniyizhai Annamalai: Yeah, right, so that’s a very good question, if any of us had a good answer for it. But I would just say that, to the extent possible, primary care physicians arm themselves with the knowledge that would help them. I know a lot of primary care physicians would be comfortable prescribing antidepressants and going through steps one, two, three of treating behavioral health conditions, but may not be as comfortable going beyond that. There are resources for primary care physicians, either within internal medicine societies or conferences, or sometimes going to the psychiatric associations, where sometimes even our group has had courses for primary care physicians on how to treat behavioral health conditions.

So it’s arming yourself with the knowledge. And then, I know primary care practices are often strapped for resources, but it’s using your social worker, or whoever you have access to, to find those services in the area. Because oftentimes, even if you don’t find anybody easily to treat anxiety or depression, when it reaches the level that they’re having multiple hospitalizations, or they need a higher level of care with wraparound services, usually state mental health facilities are available. Again, they have waiting lists, and they’re not perfect, but a lot of times your local state mental health agency will be able to take them on and provide that resource, just like our CMHC is. It’s the local go-to place for people who haven’t been able to get care anywhere else.

Kevin Pho: All right, let’s talk about your KevinMD article, titled “Medicare ‘Advantage’ for my indigent patients.” Now, how did this article come together?

Aniyizhai Annamalai: So a little about insurance. My only dalliance, or brush, with insurance would be when I got pushback because I had to do prior authorizations, either for medications or for procedures. And I didn’t think much about it until I started exploring this for my own parents, who are elderly and who have been on Medicare for a few years. The last few years, we’ve been getting more and more advertisements to join one of the Medicare Advantage plans, and we didn’t look into it too seriously until this year, when they themselves had some health conditions develop, and we thought, “OK, we need to look into this more.”

And when we did that, I realized that there were actually two things. One was the traditional Medicare, and then there were the Medicare Advantage plans, which I didn’t quite realize until then. And I also realized that one of the bigger differences between the two is that traditional Medicare only covers about 80 percent of your costs, and the 20 percent is hard for most people to cover, so most people need to get a supplemental insurance plan. And the advantage with these Medicare Advantage plans is that it’s just one plan. You don’t need to get a supplemental plan; you’re just covered by one thing. So it seems like a good thing.

But while I was thinking through this, I suddenly realized that my patients also all qualify for what’s called the QMB. That’s a Qualified Medicare Beneficiary. When they qualify for the QMB program, anything that Medicare does not cover, including that 20 percent, is basically paid for by it. It’s picked up by the QMB, which is usually their local Medicaid. So that’s kind of like a backup insurance. So then the big benefit that people have with the Advantage program is kind of lost for them.

Then I started looking into whether maybe there are other advantages, other reasons why they should be on this. But the more I looked, the less I found information to convince me that this is a good thing for them. For example, dental benefits are one thing that Medicare Advantage plans frequently offer, but not only do they cover very little for my patients, especially in the state of Connecticut, Medicaid does cover the dental plans. So that wasn’t really an advantage.

And then I realized one other important thing. Typically, people who are on these Medicare Advantage plans, and are even happy with them, when they get sicker, when they get older, when they have more health problems and they need to access health care more, seem to want to switch back to traditional Medicare. To me, that means that if you’re sicker, then you actually are going to need this, but if you are mostly healthy and just need your preventive care, then the Advantage plans might be OK. So after all this, the reason that they typically want to switch back, it seems like, is that they are not able, from what we know, to access high-quality care at specialty hospitals, for example. They have more out-of-network barriers, for example.

And my own personal example that I referenced in my write-up was when my mother needed specialty care. I didn’t have to ask the insurance plan. I just took her, even though it was out of state. I took her to a specialty hospital, and she was able to receive her care without me ever even talking to the insurance. That’s because traditional Medicare is accepted by almost everybody, all hospitals in the country, whereas the Medicare Advantage plans are usually geographically limited, and you can’t just go to the best place that you want. So typically, the reason for switching seemed to be when people need higher-quality care at a specialty hospital, or the number of doctor visits and the number of hospital visits keep increasing and they need a higher level of care, and then they start to experience more restrictions and pushback from their insurance.

Kevin Pho: Now, to my understanding, the Medicare Advantage plans are mostly run by private insurers, and in some cases for-profit insurers. Is that correct?

Aniyizhai Annamalai: That’s correct. I don’t claim to be an expert on this, but from what I’ve been reading, once I started getting interested in this, there are a lot of people, for example Don Berwick, who used to run the Centers for Medicare & Medicaid Services, who have written about this. But they’re all for-profit companies, and I think that really incentivizes them to push and aggressively market, which is, I think, my fundamental problem with it. Whether they are better or not can be decided by the individual, but it shouldn’t be that when you are eligible for Medicare, all you hear is from the private companies, and you hear nothing about traditional Medicare from the government. That, I think, really makes for an uneven playing field.

And one of the things that I was really surprised by in the last year or so is that my peers, whether they’re physicians or not, I think have a very limited understanding of this. I asked several friends who are older, who are on Medicare, “What are you on?” and most people couldn’t really tell me. My worry at this point is that most people have even forgotten that there is a traditional Medicare option. People, I think, at some level realize there are these private Advantage plans, and there are different plans, and you have to choose a plan that works for you. But beyond that, I don’t think people realize that there’s even an option not to be on one of these plans. Unfortunately, traditional Medicare does not have prescription coverage, so everybody needs some private plan for that. But you could choose to have just that, and not have the private plan for your hospital and doctor visits and all that, which I think most people don’t realize, which for me was the biggest disappointment when I was learning about all this.

Kevin Pho: So let’s say for your patient population, who have a choice, they’re about to be 65, and they have a choice between traditional Medicare and Medicare Advantage. What kind of advice are you giving them?

Aniyizhai Annamalai: Yeah, so I realized all this that I learned only very recently. So I started looking into my patients’ records, and I confirmed that pretty much everybody that was on Medicare was on an Advantage plan. So I’ve started talking to people in our clinic, our social workers and other health care workers who are there to help these patients, about this. I am trying to increase awareness among our communities so that they can help me help our patients at least know what their options are, and even if they’re choosing to stay with one of the private plans, to choose the one that’s best for them. Because as I referenced in my article, I frequently had situations where the patient will say, “Oh, my plan changed,” and then they will tell me all the medications that need to be changed, which is unnecessary unless they’re actually getting a definitive benefit.

So I am hoping to not just directly talk to my patients, but at least within our mental health center, to create some sort of system where we at least know where to direct patients. One agency that I came across is basically the state Medicare assistance program, which is run by Medicare, which is government-sponsored. I have not personally tested it, but I’m hoping that they can give advice that’s neutral. Because when you have an incentive, then your advice is not going to be neutral, and any Advantage insurance agent will have an incentive to sell his or her plan. So I want people to go to a place where they get advice that’s not biased, and I’m trying to make that happen in our workplace, at least before the next insurance enrollment period comes this coming November.

Kevin Pho: Now, for someone who’s listening to this and may want to switch from Medicare Advantage back to traditional Medicare, what’s the process for that?

Aniyizhai Annamalai: So Medicare, this actually can be quite helpful. There’s actually a process, especially if you know how to navigate it. And again, it might be difficult for people like my patients; they might need help. But just calling the Medicare number or navigating through their website, you can actually put in your geographic region and the things you want and what you need to do, and it’ll actually take you through the process. But especially when you call Medicare representatives outside of the insurance enrollment period, they will have more time. So I would actually encourage people to do that before the enrollment period starts, to just get all the information ready so that they can make that switch.

And I would also say, even for the physicians listening to this, for themselves, when they are heading toward Medicare, to just look into this, to really do the due diligence and do the research before just signing up for a plan when you become eligible.

Kevin Pho: We’re talking to Ani Annamalai. She is an internal medicine physician and psychiatrist. Her KevinMD article is titled “Medicare ‘Advantage’ for my indigent patients.” Ani, what are some of your take-home messages that you want to leave with the KevinMD audience?

Aniyizhai Annamalai: So I think we all, as physicians, have a ton of things to do, and we are very busy, and we barely have time even to see patients. But I would really encourage people to get immersed in this a little bit more and understand what system is being run for our health care. And we all know this is not a novel idea; this is not new. But I think I just want to emphasize that our health care system is too fragmented, and health care really shouldn’t be a commodity. It shouldn’t be this complicated for us to understand. And I think in whatever little way we can, whether it’s by helping our own patients, or whether it’s making systemic changes or advocating to our elected officials, I think we should all try to do a little bit to make our health care system simpler than it is now.

Kevin Pho: Ani, thank you so much for sharing your time and insight, and thanks again for being on the show.