Well-liked Medicare plan vs. higher-ranked providers - ChicagoNow

Medicare Open Enrollment ends December 7. The easy choice is to stay with all-in-one Medicare Advantage instead of switching to Traditional Medicare plus a supplement and drug plan. The hard one is whether to switch between Medicare Advantage plans, from a well-liked one to one accepted at a so-called top-10 hospital.

Humana Gold Plus, a Medicare Advantage HMO, has served me well for five years. Hearing aids cost me only $10 after its $2,000 allowance. Routine doctor and dentist appointments and my medication cost nothing.

But Humana Gold Plus is not accepted by Northwestern Memorial Hospital, the nearby hospital that US News & World Report ranks as the tenth best in the country, or by Northwestern Medicine physicians. My primary care physician is in an Advocate Medical Group. If I were hospitalized, it would be at Advocate Illinois Masonic Medical Center. If I had a serious illness, I’d see specialists in Advocate’s network.

Illinois Masonic is not a second-rate hospital, and Advocate’s provider network is vast. But it’s hard to disregard NHM’s reputation. Along with listing it among the country’s 10 best, US News ranks NMH nationally in 12 adult specialties and high performing in 9 adult procedures. Illinois Masonic appears on only two of those lists.

Switching insurance plans would not require switching to Traditional Medicare. Unlike when I first went on Medicare, there are now zero-premium Medicare Advantage PPOs that Northwestern accepts. PPOs allow members to pay more to go outside the network, but when the network has so many stellar specialists, there’d be little call to go outside.

On the other hand, I like my Advocate doctor. The Medicare Advantage PPOs have higher copays or fewer benefits than Humana Gold Plus. They don’t cover hearing aids, and hearing aid replacement is due. The Center for Medicare and Medicaid Services rates Humana Gold Plus the highest among Cook County Medicare Advantage plans.

As I get older, the more difficult the Open Enrollment choice becomes. How long will good health last? How important is access to the presumed best hospital and doctors? How much attention should be paid to US News hospital rankings?

In an interview in the publication HealthLeaders, University of Michigan healthcare researcher Melissa Riba praised the US News rankings for their rigorous criteria but said that a consumer should not rely on just one ranking. Other quality surveys apply different criteria and produce different results. Industry expert Paul Keckley agrees that information seekers “must compare among several sources to get a complete picture of a hospital’s performance.”

CMS’s Hospital Compare provides patient perspectives in more than two dozen categories. Both Northwestern and Illinois Masonic get three stars our of five, a middling performance that reflects an urban hospital’s treating poorer and sicker patients.

Illinois Masonic has been a Watson Health (formerly Truven) Top 100 Hospital for eight years and is the only Chicago institution on the list. The hospitals in the top 100 are high performing on measures such as 30-day readmissions, mortality rates, patient experience, and profit margins.

HealthGrades gives both Illinois Masonic and NMH quality awards for gastrointestinal and stroke care, general surgery, and neurosciences. Advocate gets an award for critical care and NMH for cardiac care. Eighty percent of NMH patients, and 73 percent of Illinois Masonic’s, would give the hospital a rating of 9 out of 10.

Other hospital quality survey takers include Leapfrog, Propublica, Consumer Reports, the Commonwealth Fund, and the Joint Commission. Each uses different criteria.

Among the surveys I looked into, it’s only US News where NMH shines much brighter than Illinois Masonic. I’ve reassured myself that I’m not jeopardizing my health by staying with Advocate. Most procedures don’t require a top-10 hospital. Most conditions don’t require an eminent specialist.

It’s the complicated or nearly hopeless conditions for which people seek out the hospitals and physicians at the top of US News lists. I would want state-of-the-art expertise in a medical crisis, but it’s impossible to predict the need. For next year, I’m sticking with my current providers and will take advantage of Humana’s generous hearing aid benefit.

The chance to reevaluate plans will come again next year.

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