LIHU‘E — A five-star rating for a senior health care plan has an asterisk when it comes to serving Kaua‘i. When Kapa‘a resident Diane Blaize becomes a senior citizen eligible for Medicare next year, she will have to either switch
LIHU‘E — A five-star rating for a senior health care plan has an asterisk when it comes to serving Kaua‘i. When Kapa‘a resident Diane Blaize becomes a senior citizen eligible for Medicare next year, she will have to either switch health care provider or bite the bullet and pay more for her Kaiser Permanente plan.
The Centers for Medicare & Medicaid Services in January gave a five-star service rating to Kaiser Permanente’s 2013 Senior Advantage plan. CMS developed the rating system for health plans that maintain all Medicare Advantage, and despite the strong statewide rating, Kaiser has does not offer Senior Advantage on Kaua‘i.
“Our Medicare Advantage plans are not currently available on Kaua‘i, Moloka‘i, and Lana‘i (and three zip codes on the Big Island) because establishing the needed infrastructure would be cost-prohibitive,” said Laura Lott, director of Community and Public Relations for Kaiser Permanente Hawai‘i. “It is a different product with different costs, co-pays, services and benefits.”
To be eligible for a health plan with a Medicare contract, seniors must reside in the Kaiser Permanente Senior Advantage service area in which they enroll, according to Lott. Only O‘ahu, Maui, and parts of the Big Island have Kaiser healthcare facilities within 20 miles or 30 minutes of their clients as required by Medicare.
Though Kaiser left Kaua‘i nearly a decade ago, the company still provides individual plan coverage for Kaua‘i residents by contracting with local physicians and hospitals. They fly patients off-island for specialists when necessary.
Medicare policy says providers cannot outsource doctors, and Kaiser would need to invest in a Kaua‘i facility to offer the senior plan here, Lott said. Kaiser says it has no plans to consider opening a facility on Kaua‘i, where it would need to provide emergency services or contract with other facilities.
Blaize joined Kaiser Permanente after friends recommended the health maintenance organization. The former store-owner wants to stay with Kaiser as a senior citizen.
“I really like the Kaiser doctors,” Blaize said. “I wanted to change over to the Senior Advantage plan when I am eligible for Medicare a year from April.”
It makes sense for someone to stay with a health system for their entire life, Blaize said. Specially as a senior citizen, she said it is beneficial to remain with the same familiar system at a time when health becomes more and more a priority.
After calling Kaiser to inquire about the Senior Advantage program, Blaize said she was told it was not available on Kaua‘i and that she must find another senior plan. She could remain with her current Kaiser individual plan that would increase in cost once she is eligible for Medicare.
Blaize said Kaiser should reconsider Kaua‘i, based on potential growth of the senior population, but more because of its obligation to quality of care as a nonprofit healthcare provider.
“It is small minded to think that no seniors on Kaua‘i would want to join,” Blaize said. “It goes back to Kaiser choosing not come to Kaua‘i.”
The Senior Advantage plan requires a minimum population to make it financially viable and affordable to the members, Lott said.
“Establishing a Medicare Advantage Plan on Kaua‘i would require a significant investment to ensure both the adequate provider base and provide the high quality five-star results that Kaiser Permanente has committed to achieve,” Lott said.
State Rep. Dee Morikawa, D-16th District, said insurers look at the bottom-line and that is why Kaiser pulled out of Kaua‘i.
“Without a population base you can’t make money,” Morikawa said.
It is cheaper to get people on individual plans to fly to O‘ahu, she said. The elderly have more health problems and they tend to get written off, she said.
“Hospitals take a big hit with the uninsured,” she said. “It is tough for any nonprofit to make money and fortunately for us we have a nonprofit on Kaua‘i.”
The Kaua‘i Area Plan 2012-2015, notes that the number of adults over age 60 has grown at a higher rate since 1980 than the overall island population. The ratio of older adults rose at nearly 32 percent, compared to just under 13 percent for the overall population.
As the Baby Boomer generation becomes senior citizens, Kaua‘i will continued to stand out for its high ratio of elderly retirees and services for them will be in high demand, Blaize said.
The county Agency on Elderly Affairs states that Kaua‘i County is not in a position to evaluate coverage options provided by private insurers. However, it does express concern for gaps in health insurance for seniors that Medicare does not cover.
There are now more than 200,000 Hawai‘i policy holders of Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals and Hawai‘i Permanente Medical Group, Inc.
When Kaiser left Kaua‘i it caused a rift with people who were forced to change, said Pamela Cunningham, director of Sage PLUS, a volunteer based Medicare counseling program under the Hawai‘i State Health Insurance Assistance Program, sponsored by the state Department of Health’s Executive Office on Aging. Kaiser is an example of a “one-stop-shop” for people that want all healthcare needs to be provided under one plan, she said.
The private health plans offer added protections outside of Medicare, Cunningham said. When the health plans can’t find the right doctor or service then they must help them find a doctor outside the network, including Hawai‘i Medical Services Association, ‘Ohana Health Plan, and United Healthcare.
“All the plans do that,” Cunningham said.
The feedback of Kaiser’s own customers resulted in the five-star rating. All the plans did well but Kaiser received five stars based on consumer surveys.
“The satisfaction rating in Hawai‘i is above the Mainland across the board,” Cunningham said. “There only 13 plans nationwide with five-star ratings and a lot of states don’t even have one five-star plan.”
Medicare’s value is best demonstrated in the rural areas of the Mainland, where there are sometimes no private providers, Cunningham said. In Hawai‘i, it picks up the slack with services and coverage when the providers do not have anything available.
“All of our plans as much as possible try to offer service but it is not always available on all islands,” she said. Sometimes providers have the upper hand and Medicare provides reimbursements. The hospitals on the smaller islands take everyone and the uninsured are taken care of by the health exchange, she said.
“We are lucky in Hawai‘i to have really good providers and most take Medicare,” she said. “We don’t get as many complaints on Kaua‘i as other places where the doctors don’t take Medicare.”
Blaize said she is not giving up on a Kaiser senior program on Kaua‘i. She said it took a lot of effort for the Big Island to convince Kaiser to build a replacement specialty care clinic in Kona, along with a major expansion and renovation of the Kaneohe clinic.
