10-23-2026 9:42pm

A Low Medicare Premium Means Little If Patients Can’t Get Timely Care

Beth Callahan Editor

Emmett C Roper, Jr., MD, Contributed photo

By Emmett C Roper, Jr., MD, Primary Care, Internal Medicine Mercy Health—Cincinnati

WARREN COUNTY, OH -- Every fall, millions of Americans review their Medicare coverage options. Most focus on monthly premiums, prescription drug coverage and supplemental benefits. I understand that; healthcare costs matter, especially for people living on fixed incomes.

But as a physician caring for patients in Cincinnati, I’d encourage patients to ask another question: How will this coverage affect my ability to access care when I need it?

That question may be especially important this year. Recent reporting points to broader changes across the Medicare Advantage market, including reduced supplemental benefits, narrower provider networks and higher patient cost-sharing in some plans for 2027. These developments are a reminder that Medicare plans are not all alike and that beneficiaries should look carefully at how coverage may affect both affordability and access to care.

Differences in provider networks, referral requirements and prior authorization rules may seem less important when someone is healthy. But they can become especially important when a patient is facing a serious illness, recovering from surgery, managing a chronic condition or seeking specialized treatment.

In my experience, some of the most difficult conversations happen when a patient needs care and learns that insurance requirements may affect where, when or how that care is delivered. That's why I encourage patients to look beyond cost alone and understand how coverage rules may affect their access to care.

How Prior Authorization Affects Patients

Prior authorization is a process some health plans use to review certain treatments, tests, medications or services before agreeing to cover them. While often described as a cost-management tool, it frequently places insurance companies between patients and the care their physicians recommend. Even when a physician determines a treatment is medically necessary, clinical teams may need to submit medical records, provide additional documentation, participate in reviews or file appeals before care can move forward. Those administrative requirements can delay or deny treatment, forcing healthcare decisions to be driven by coverage rules rather than clinical judgment.

Recently, I cared for a patient who needed medication for pain after surgery. Clearly, there was a need for the patient to have access to the medication, however, when his family went to pick up his medication, they were told that it would need prior authorization by the insurer. The clinical indication was clear, however, the insurance company insisted that they review the need for it even with the knowledge of the patient having had surgery that day. The patient had to wait, in pain, for 3 days before he could get his medication and the company didn’t pay for it because one of the patient’s family members paid for it out of pocket because they couldn't tolerate watching their relative suffer in pain any longer. Reimbursement for the expense was not given by the insurer. This is just one clinical vignette about how prior authorization interferes with delivery of good care. There are many other stories outlining how the delay and/or denial of care prolongs illness or interferes with the best management of patients with chronic conditions including diabetes, heart failure and emphysema.

Recent public reporting has highlighted how often prior authorization requests are denied and how frequently appealed decisions are later reversed. That should concern patients and physicians alike. Coverage decisions should be timely, transparent and based on consistent clinical standards, with a fair process for review when physicians believe care is medically necessary. Instead, the high reversal rate on appealed decisions suggests that treatment is often unnecessarily delayed when patients are forced to prove they deserve care that their doctors have already determined they need.

Delays in care have consequences. A postponed scan can delay a diagnosis. A delayed treatment can prolong suffering. A delayed rehabilitation stay can slow recovery. At the same time, patients face uncertainty while physicians and clinical staff spend time navigating paperwork, reviews and appeals. The result is a healthcare experience that is more stressful and less efficient for everyone involved.

Questions To Ask Before Enrolling

That is why I encourage beneficiaries to ask practical questions before enrolling: Are my physicians, specialists and preferred hospitals in network? What referrals or prior authorizations are required? What happens if a request is denied? What will I pay for primary care, specialists, hospital care, rehabilitation, medications and out-of-network services? And are added benefits meaningful for my needs, or limited by eligibility rules, provider networks or annual allowances?

Patients should also understand that Medicare coverage options are not all alike. Original Medicare is accepted by most physicians and hospitals nationwide and generally offers broad provider choice and flexibility, though many beneficiaries purchase additional coverage to help with out-of-pocket costs and prescription drugs. Medicare Advantage plans often combine medical and prescription drug coverage and may offer additional benefits, but they can also have provider networks, referral requirements, cost-sharing rules and prior authorization requirements. The right choice depends on a person's doctors, medications, healthcare needs, budget and preferences.

At the end of the day, patients should be able to focus on their health, not navigating avoidable administrative hurdles. Whatever coverage they choose, they deserve a healthcare system where physicians and patients, not paperwork and approval processes, are the primary drivers of care decisions.