Beyond the Exam Room: What if Medicare Gave Patients the Money?
BEYOND THE EXAM ROOM
Transforming Healthcare & The We The Patient Movement
What If Medicare Gave Patients the Money?
A recent Becker’s Hospital Review article asked a question that caught my attention:
What are taxpayers actually buying with Medicare Advantage?
The authors make an important point. For years, Medicare Advantage has rewarded plans for becoming increasingly sophisticated at documenting how sick their members are. They argue that the next era should focus on something much more meaningful: How much healthier are you making your members?
I think we should take that question one step further. What if we gave patients and their physicians more control over the Medicare dollars being spent on their health?
We have become very good at documenting illness
Medicare Advantage is no longer a small alternative to traditional Medicare. About 55 percent of eligible Medicare beneficiaries are now enrolled in Medicare Advantage.
MedPAC estimates Medicare will pay Medicare Advantage plans approximately $615 billion in 2026.
Medicare Advantage payments are adjusted partly according to how sick their members are. Documenting additional diagnoses can increase a patient's risk score and potentially increase payments to the plan. The more sick the patient, the more tax payer dollars to the plan and hence the more focus on documenting illness (more codes). The Becker’s authors point out that the industry has invested enormous resources and technology into finding diagnoses, improving documentation and optimizing risk scores.
But I keep coming back to a simple question: Does documenting that someone is sick actually make them healthier?
Another diagnosis code does not lower someone's blood sugar.
It does not lower blood pressure.
It does not prevent kidney disease.
It does not help someone lose weight.
It does not keep someone independent in their own home.
We have become remarkably sophisticated at documenting disease.
What if we became equally sophisticated at creating health?
What if some of the money followed the patient?
Medicare Advantage plans also receive what Medicare calls rebate payments. Those dollars are used under Medicare rules for supplemental benefits, reduced cost sharing, premium reductions and other permitted purposes. But those dollars generally do not go into an individual healthcare account controlled by the patient. The plan receives and manages them.
What if we tried something different? What if some of those dollars followed the patient into a regulated Medicare health account that could only be used for qualified healthcare expenses?
Then let patients work with their physicians to decide where those dollars could have the greatest impact on their health.
Insurance companies understand populations and financial risk. Physicians understand medicine. Patients understand their own lives, goals and challenges. Maybe we should give the last two more control over the dollars intended to make that individual healthier.
Consider two patients with type 2 diabetes.
On paper, they may have exactly the same diagnosis code —> but they may need completely different things.
One may need medication.
Another may need nutritional counseling.
Another may be unable to exercise because of arthritis.
Another may need help understanding how food, activity and sleep affect their blood sugar.
For an appropriate patient, the physician and patient might decide that a continuous glucose monitor could be valuable. Imagine being able to see what happens to your glucose after breakfast. What happens after eating a particular food. What happens after taking a walk. What happens while you sleep. For the right patient, that information can help make an invisible disease visible and may help the patient make meaningful changes.
A CGM does not replace insulin, metformin or other medically necessary treatment. It will not be appropriate for everyone.
That is exactly the point —> Healthcare is not one size fits all.
The question should not simply be, “What benefit does this plan offer everyone with diabetes?” It should also be:
What does this particular person need to become healthier?
What if we rewarded getting better?
This is where I think the Becker’s article gets to the heart of the issue.
The authors argue that Medicare Advantage should move from rewarding coding to rewarding caring. I would take that one step further. Let's reward health.
Instead of primarily becoming better at documenting how sick people are, imagine if we became just as good at measuring whether they got better.
Did the patient's diabetes improve?
Did their blood pressure improve?
Did they maintain kidney function?
Did they stay out of the hospital?
Did they remain mobile?
Did they remain independent in their own home?
How many healthy days did they have at home?
Those are outcomes patients understand. They also have enormous economic consequences. The goal should be needing less healthcare, not simply paying for less healthcare There is an important distinction here. The goal should not simply be to spend less money on healthcare. The goal should be to help people become healthier so they need less expensive healthcare.
Diabetes is a perfect example.
Diabetes can lead to kidney disease, cardiovascular disease, stroke, blindness, neuropathy and amputations. Those complications can be devastating for patients and extraordinarily expensive for Medicare. The CDC estimates that 48 to 64 percent of lifetime medical costs for a person with diabetes are related to diabetes complications.
What if we invested more aggressively before those complications occurred?
For one patient, the best investment may be medication.
For another, a CGM.
For another, nutritional counseling.
For another, physical therapy that allows the person to become active again.
For another, transportation that allows the patient to actually get to medical appointments.
Not every preventive intervention saves money, and we should not pretend it does. But preventing serious complications can avoid substantial downstream healthcare costs while accomplishing something far more important. —> The patient becomes healthier.
What are taxpayers actually buying?
The Becker’s article raises a question I believe every Medicare patient and taxpayer should be asking. MedPAC estimates that Medicare Advantage plans are projected to spend 15 to 18 percent less on medical services than comparable care would cost in traditional Medicare. Yet Medicare is projected to pay Medicare Advantage plans more overall than it would spend for comparable beneficiaries in traditional Medicare.
Why? If Medicare Advantage plans are spending less on the actual medical care patients receive, why are taxpayers paying them more? And where does the difference go?
Many of the largest Medicare Advantage insurers are publicly traded, for profit companies. That means they have shareholders and, like other publicly traded companies, are expected to generate profits and returns for their investors. Traditional Medicare is different. It is a public program. It does not have shareholders expecting a return.
To be clear, the difference between what Medicare pays Medicare Advantage plans and what plans spend on medical services does not simply become profit. Those dollars also pay for supplemental benefits, administration and other costs. But some of the public dollars flowing through Medicare Advantage can ultimately contribute to insurer profits and shareholder returns.
That troubles me.
These are Medicare dollars intended to care for our seniors and people with disabilities. If the government is paying private plans more while those plans are projected to spend less on medical services, I believe taxpayers deserve to know exactly what value they are receiving for those additional dollars.
And it makes me ask an even more fundamental question:
Would some of that money do more good in the hands of patients instead of contributing to the profits of publicly traded insurance companies?
Imagine giving a patient greater control over some of those healthcare dollars and allowing that patient to work with their physician to invest in what could actually improve their health.
A continuous glucose monitor.
Nutritional counseling.
Physical therapy.
Medication.
Transportation to medical appointments.
Whatever is medically appropriate for that individual patient.
I would rather see Medicare dollars invested in helping a patient become healthier than contributing to a shareholder's return. That is ultimately the question I want my patients to understand: Who should benefit most from Medicare dollars: the patient whose health depends on them, or the investors who own the company managing them?
What If More of the Money Went Directly to Patients?
This idea is not as radical as it may sound. Medicare already has Medical Savings Account plans that combine high deductible coverage with a medical savings account patients can use for healthcare expenses.
Why not expand that idea?
Keep insurance protection for hospitalization, cancer, surgery and catastrophic illness. But put some Medicare dollars directly into a regulated health account controlled by the patient. Then let patients and their physicians decide how those dollars can best improve their health. For one patient that might mean medication. For another, a continuous glucose monitor, nutritional counseling or physical therapy.
Healthcare is not one size fits all. Neither should healthcare spending be.
This brings us back to the central point raised by the Becker’s Hospital Review article.
Medicare Advantage has become very good at documenting illness. What if the next model put more power and dollars in the hands of patients and physicians to create health?
Give patients more control. Let physicians practice medicine. Keep insurance for what insurance does best: protecting patients from major financial risk. The goal should not simply be spending less. It should be helping people become healthier so they need less healthcare.
Sources
Pronovost PJ, Bond B. Medicare Advantage is making billions. Taxpayers deserve to know what they are buying. Becker's Hospital Review. 2026.https://www.beckershospitalreview.com/finance/medicare-advantage-is-making-billions-taxpayers-deserve-to-know-what-they-are-buying/
Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. March 2026. Medicare Advantage program status and payment estimates.https://www.medpac.gov/
Centers for Medicare & Medicaid Services. Medicare Advantage and Part D payment policies and program information for 2026. CMS.https://www.cms.gov/medicare/payment/medicare-advantage-rates-statistics
U.S. Department of Health and Human Services, Office of Inspector General. Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials. 2026.https://oig.hhs.gov/
Medicare.gov. Continuous Glucose Monitors. Centers for Medicare & Medicaid Services. Medicare coverage requirements for continuous glucose monitoring.https://www.medicare.gov/coverage/continuous-glucose-monitors
Centers for Disease Control and Prevention. Diabetes: Health and Economic Benefits of Diabetes Interventions.National Center for Chronic Disease Prevention and Health Promotion.https://www.cdc.gov/nccdphp/priorities/diabetes-interventions.html
Centers for Medicare & Medicaid Services. Medicare Medical Savings Account Plans. Information regarding Medicare MSA plans, deposits and beneficiary use of account funds.https://www.cms.gov/medicare/health-drug-plans/medical-savings-account
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