(The opinions expressed herein are those of the author.
January 14 () – Over the past two decades, millions of retirees have opted to abandon the traditional Medicare program and join a privatized, managed care version of the program. But the choice may not be in their hands.
The U.S. government has extensively tested a new model for traditional paid Medicare, with critics arguing it could turn it into another type of privatized managed medical care. Under the model, Medicare will contract with medical care groups that receive an annual flat fee to care for those enrolled in a traditional program. Paid Medicare registrants for some current services are being placed with Direct Contracting Organizations (DCEs) in 38 states where they are undergoing testing.
DCEs are groups of physicians, hospitals, or other health care providers that work as a team to improve the quality of care and patient experience. But they all have one thing in common with Medicare Advantage, a fast-growing managed care offer that already serves 42 percent of Medicare registrants. Like priority plans – typically HMO or PPO plans – DCEs create a network of preferred health care providers and they can retain the unspent part of their annual health care payments for each patient as a benefit.
The Centers for Medicare & Medicaid Services (CMS) describe DCEs as part of a broader strategy to improve traditional Medicare through innovative accountable care organization (ACO) models, and say it is a test.
“CMS recognizes that good health outcomes and coordination can be achieved through a variety of approaches,” said Dr. Liz Fowler, Deputy Administrator of CMS and Director of the CMS Innovation Center, via email in response to questions I sent. “A direct contracting organization is one of the approaches that can help achieve that goal.”
Proponents argue that DCEs improve traditional Medicare, while providers create financial incentives to coordinate care for patients and focus on improving their overall health.
“This is a transition from a more cost-split-paid model to a prepayment system that turns into a health care system, not a sick system,” said Don Crane, CEO of American Medical Groups, who advocates per capita payment. ‘ib trading group. models for health. “It’s a system where doctors work together to keep patients healthy.”
But the trial raises questions among consumer advocacy groups and some members of Congress about how DCEs affect patient care. They are also concerned about the influx of investor-led business revenue, which points to further privatization of Medicare. Perhaps most importantly, they argue that such a significant change in the structure of Medicare should require the approval of Congress, not regulation by the CMS.
While the DCE program is in its infancy, it is very clear: if you are registered with a traditional Medicare and live in an area where DCE operates, you can be assigned to one without your consent. The CMS does this by reviewing your claim history and “touching” you to the DCE (or if you choose to join) that your doctor attends. You will receive a letter stating that your healthcare provider is part of the DCE.
To refuse, you will need to go to a doctor who is not a DCE member. And Medicare officials note bit.ly/31Svpyv that all traditional Medicare beneficiaries will be in a “care relationship with responsibility for quality and cost of health care” by 2030. Fifty-three DCEs are currently in operation.
Agreeing with DCE does not change the package of Medicare benefits that apply to you, but it can use financial incentive methods to restrict access and encourage the use of services that it deems unnecessary. network providers.
Refusal of care, high COST
The Affordable Care Act gives the CMS the right to approve innovative health care models, such as the DCE – if they improve the quality of patient care and reduce costs. But there are compelling reasons to question whether DCEs will achieve these goals.
Critics of Medicare Advantage point to research that documented problems with refusing help. A 2018 report by U.S. Department of Health and Human Services investigators identified a “common and persistent” pattern of misrepresentation of patient claims. The report also concluded that the Advantage payment model could encourage plans to “pre-authorize services for beneficiaries and refuse payments to providers to maximize profits”.
Theoretically, competition between per capita health care plans would improve the quality and efficiency of health care and help save money for the federal government. But research has shown that Advantage plans charge billions of dollars in overpayments because they have the right to charge Medicare for sick patients under their care. Bit.ly/3zT0YVj According to a recent study, Medicare paid more than $ 106 billion for Advantage plans from 2010 to 2019 due to a miscalculation of risk.
Richard Chronicle, a professor and research author at the University of California, San Diego, said: “Preference plans find and report more diagnoses for their members than beneficiaries in traditional Medicare.” “Medicare should adjust the fees downwards to reflect the differences in reporting diagnoses in the two programs, but it hasn’t fully done so,” he added. “As a result, the plans are getting paid a lot.”
Medpac, an independent congressional agency that advises legislators on Medicare, is a regular bit.ly/3qjigrB similar to the one registered in the Pay-Contract Program for beneficiaries registered in the Medicare Medicare Advantage Program. found that it paid more than the beneficiaries.
The pilot program for DCEs has moved forward without public attention, but it has begun to change. Last week, more than 50 Democrats in Congress called on the Biden administration to end the DCE pilot test on bit.ly/34zYzDk. Physicians under the National Health Plan and other single-payer health advocates are also working to stop the program.
“Under good old-fashioned traditional Medicare, you can go anywhere you want across the network,” said Dr. Ed Weissbart, chairman of the National Health Physicians Program for Missouri, against single-payer health plans. fighting group. DCElar. “We know that Medicare Advantage companies make the most money when they direct you softly or firmly to their preferred providers.” (Written by Mark Miller, edited by Matthew Lewis)