How Long Do Medicare Enrollees Wait to See a Doctor?

A third face month-long delays for appointments, but most are happy with their overall care

A survey of beneficiaries enrolled in both original Medicare and Medicare Advantage (MA) plans revealed a common problem: More than a third of those polled had to wait a month or more to get in to see a doctor. And Advantage enrollees are more likely than original Medicare beneficiaries to face delays getting care because the health plan had to approve the service ahead of time.

Despite the wait-time issue, more than two-thirds of beneficiaries — whether enrolled in original Medicare or an MA plan — say the health care program for older Americans and people with disabilities is fully meeting their expectations, according to a new report from the Commonwealth Fund, a nonpartisan think tank.

Commonwealth conducted the survey between Nov. 6. and Jan. 4. It commissioned a nationally representative telephone and online sample of 3,280 Medicare beneficiaries who were asked about the value of their care, measuring such factors as access to benefits, services, providers, whether their care was coordinated and how satisfied they were. There were 1,946 survey respondents in Medicare Advantage and 1,334 respondents in traditional Medicare.

Wait times can be long

“This isn’t the first data to show that many people on Medicare have to wait over a month to see a physician,” says Gretchen Jacobson, vice president for Medicare at Commonwealth and lead author of the report. “It is very concerning and it’s very interesting that people are having similar experiences in Medicare Advantage and traditional Medicare with this.”

Thirty-six percent of survey respondents who were enrolled in an Advantage plan said that within the past two years they had waited more than a month to see a doctor, while 34 percent of original Medicare enrollees had such a wait.

What the survey does not say, Jacobson cautions, is whether people are having to wait more than a month to see a doctor for an urgent problem or for more routine care.

“CMS is committed to ensuring that people with Medicare Advantage and traditional Medicare have timely access to medically necessary care and we appreciate the stakeholders’ and the public’s feedback to our programs,” Meena Seshamani, M.D., director of the federal Centers for Medicare & Medicaid Services (CMS), says in an emailed statement.

Agency regulations for Medicare Advantage plans set wait-time standards for primary and behavioral health care. They say that enrollees should get care immediately for urgently needed or emergency services; within seven business days for care that isn’t an emergency but something for which an enrollee needs medication attention; and within 30 days for routine and preventive care. CMS officials have not said whether these standards also apply to providers who treat enrollees in original Medicare and how the wait-time standards are enforced.

Prior authorization can lead to delays

A major focus of the Commonwealth survey was to determine whether people’s experiences with Medicare differed based on whether they are enrolled in original or an Advantage plan. “Overall, it appears that the experiences of people are similar regardless of their type of coverage,” Jacobson says. “The bottom line is that people seem to be relatively happy with their coverage.”

Sixty-five percent of enrollees in original Medicare and in Medicare Advantage said that their coverage “fully” met their expectations. Another 31 percent of MA plan members and 28 percent of original Medicare beneficiaries said the program “somewhat” met their expectations.

There was a difference, the survey found, when it came to people who reported their care was delayed because it needed advance approval, often called prior authorization. Among those with an MA plan, 22 percent said their care was delayed while they waited to get it approved, while only 13 percent of respondents with original Medicare had to wait for an OK.

“Improving the prior authorization process is a priority for CMS,” Seshamani says. “In MA, CMS is removing barriers to ensure MA enrollees get the care they need and are entitled to.” CMS officials pointed to a new regulation designed to streamline the prior authorization process by, for example, improving the electronic exchange of health information.

Extra services underutilized

Medicare Advantage members who took the survey were also asked about their use of the extra benefits that MA plans are authorized to offer. These include such services as dental, vision and hearing care, services that are not covered under original Medicare.

The survey found that 69 percent had not used any of their supplemental benefits, and about a quarter of those respondents said they didn’t use them because they didn’t know what benefits they had, Jacobson said. Forty-two percent said they used their dental benefit and 41 percent said they used their vision benefit.

CMS officials have recognized that often enrollees do not take advantage of some of these extras. Under a proposed regulation, expected to be finalized this year, halfway through each year insurers will have to send a letter to enrollees letting them know what services they are entitled to but haven’t used.

“This new policy should really help those beneficiaries who weren’t aware of what benefits their plan offered,” Jacobson says.

https://www.aarp.org/health/medicare-insurance/info-2024/medicare-doctor-wait-times.html