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Periodic Contributor

ACO Reach scheme

Does anyone else wonder why AARP has not reported on the ACO Reach scheme which is designed to help end traditional Medicare? If they have reported on it, please send link.

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Periodic Contributor

Regardless of the program's supposed benefits, if a senior has chosen to be on traditional Medicare, their doctor or any other agent should not be able to take them off Medicare and put them into another plan without their knowledge or consent. 

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Bronze Conversationalist

@jp2306867 Your exchange of Replies with Gail1 regarding the ACO REACH model is interesting. If you read any of the links that Gail included, it is abundantly clear that ACO REACH is not an additional Medicare Plan. It is a model that Medicare is using mostly for folks with Traditional Medicare even though it is available with Medicare Advantage as well. As you may not be aware, Medicare has gone through many changes since its beginning in 1965 when it only offered health insurance benefits (Part A -Hospital and Part B -  Medical) to people over age 65. That was it. Essentially, a modified indemnification model (fee for service or FFS) that assigned a reimbursement amount for eligible hospital/medical services. Although that approach did not have incentives for quality care, it was better than nothing. As the cost of medicare increased significantly, a number of value based approaches have been implemented. In the 1970's, HMOs became available in certain locations in the USA as an alternative to the indemnification model, "Traditional Medicare", which was FFS. It is not difficult to see that the amount of service (whether medically necessary, duplicate testing, readmission) was going to increase as well as the cost in the FFS model especially since Medicare was providing a benefit payment for such service. The best example that I can think of, so the readers may understand, is working on a production line where extra pay (incentives) is based on the amount of product produced. Quality is considered, but it takes a "back seat" to production totals. So, Medicare needed to establish protocols as well as a value based approach. I believe it was in the 1990s that Medicare Choice (Part C) was introduced as an alternative to Traditional Medicare Parts A and B. As I recall, Part C was mostly HMOs wherein Medicare payments were structured to provide quality value based healthcare as opposed to the volume structure of the FFS approach. Medicare Choice evolved to Medicare Advantage (Part C) about the same time the Part D Prescription Drug Program was introduced as a voluntary additional benefit/extra premium for Traditional Medicare. Medicare Advantage now includes HMOs and PPOs which are value based managed care approaches that have attracted about 50% if the Medicare Eligible folks. So, programs such as ACO REACH have  been introduced mostly to Traditional Medicare in an attempt to provide value based quality healthcare in the FFS approach. I will try to copy and paste info from the Center Medicare Services (CMS) that provides info for the ACO REACH model https://innovation.cms.gov/innovation-models/aco-reach Please review the Highlights Section that provides important info. The first highlight addresses folks that are experiencing a serious health condition or episode that have difficulty navigating the Medical system. IMO, being part of an ACO REACH model will help with this challenge which is very valuable. I do not see any mention from CMS regarding ending Traditional Medicare. Another item that folks need to review (especially if covered by the Traditional approach) is the Medicare Prospective Payment System. I will also copy and paste info describing how Traditional Medicare pays certain providers https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/html/medicare-p... It is a complicated system to address holding down ever increasing healthcare costs. FYI, the acronym, DRG, means Diagnostic Related Grioup which is how most hospitals get paid. Essentially, a hospital gets paid based on the diagnosis, not the actual costs. It should be clear that if a person is admitted and is close to exhausting the DRG allowance, that hospital may be motivated to transfer the patient to a Skilled Nursing Facility for continued care. I would not assume that managing healthcare and its ever increasing costs is an attempt to end Traditional Medicare. Hope this helps you understand a complicated healthcare benefit - Medicare.  

Honored Social Butterfly

Their doctor gives them the info and they must acknowledge it -  did you even read the links?  They stay on original Medicare if that is what they have chosen.

 

Medicare.gov - Coordinating Your Care 

from the link:

Note

If your doctor participates in these programs, you can still see any doctor or health care provider who accepts Medicare. Nobody—not your doctor, not anyone—can tell you who you have to see. Your Medicare benefits will also stay the same.

 

Medicare.gov - Coordinating Your Care - Global & Professional Direct Contracting Model. (This is the ACO REACH model.

 

From the Medicare.gov link 

(this)  

. . . . model aims to improve primary care, lower hospital admissions and help your doctor give you high-quality care. If you have Original Medicare and your doctor participates in this model, you may get extra benefits and services to help you stay healthy or better manage a chronic condition. 

 

How does it work?

If your doctor participates in this model, you’ll get a letter from an organization called a “Direct Contracting Entity.” Direct Contracting Entities can be provider organizations (like health systems), primary care practices, clinics, health plans or other health care organizations.

 

What does it mean for my care?

Your doctor works with the Direct Contracting Entity, which may offer you extra benefits, like:

  • Help paying for some Part B-covered services.
  • The option to go to a skilled nursing facility without having to stay in the hospital for 3 days. 
  • More telehealth benefits, especially for dermatology and ophthalmology services.
  • The option to keep your current care to help you treat an illness, if you already chose to get hospice care.
  • Home visits from a health care provider (like a nurse) after a hospital stay or to help manage your care.

Your Medicare rights & benefits are protected

You’ll still:

  • Be able to see all of your Medicare providers.
  • Have access to all of your current Medicare benefits.
  • Have the option to switch health care providers at any time.

ALL the above is from Medicare.gov. - directly - copy and pasted, word for word.

 

Now you might live in a place where there are plenty of providers of all types from which to pick and choose.  You may live in a community where you have a lots of help to get you from here to there to take care of your medical and other needs.  You may live in a place where grocery stores abound.  

Everybody doesn’t have this medical infrastructure or health infrastructure in place - so if some providers, including insurance groups, get together to develop a way to treat these patients who are chronically ill with perhaps many condition in a way where their care is coordinated - I am all for it.

 

It's Always Something . . . . Roseanna Roseannadanna
Contributor
Honored Social Butterfly

Do you even know what it is?  ACO’s have been around since Obamacare was invented.

Medicare (CMS) is in charge of this Innovative development - they make the rules and sign up the insurers or doctor groups that participate.

 

Medicare.gov Coordinating Your Care

 

 

 

It's Always Something . . . . Roseanna Roseannadanna
Periodic Contributor

The program takes seniors out of traditional Medicare and puts them into Medicare Advantage for-profit insurance plans that may deny benefits. This is done without the senior's consent and knowledge. It is the lack of consent and knowledge that concerns me and needs to be changed. If someone wants or can only get/afford Medicare Advantage, ending/modifying REACH will not affect this.

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Honored Social Butterfly

NO cigar

It is for both traditional Medicare beneficiaries and MA plan - IOW it can cover whatever way one wants to receive their benefits or their placement because of the income status of the beneficiary.  (Dual Eligibles - Medicare/Medicaid or MA Special Needs Plans)

 

The real key is their doctor.  If a doctor joins or forms with other providers one of these groups - they take their patients with them because theses are the patients that are particularly underserved under the current system.  They give notice to these patients and the patient can refuse participation.  However, by refusing they might not get to keep this doctor.

 

An ACO REACH group treats patients in a much wider medical net because they need this for their various conditions.  They treat the patients in more of a total body method - the group works with other providers under this arrangement -other docs, specialist, labs, plus mental health providers even home health.  

 

CMS.gov - Innovation - ACO REACH

 

from the link 

  • The health care system can be challenging to navigate, particularly for patients with chronic conditions and those who receive care from multiple providers who do not communicate with each other. These patients often receive unnecessary, repeat diagnostic tests or conflicting treatments for their different health conditions, and their primary care physician, if they have one, may not have a full picture of the treatment received by other providers.
  • The ACO Realizing Equity, Access, and Community Health (REACH) Model encourages health care providers — including primary and specialty care doctors, hospitals, and others — to come together to form an Accountable Care Organization, or ACO. ACOs break down silos and deliver high-quality, coordinated care to their patients, improve health outcomes, and manage costs. 
  • Patients in a REACH ACO get help navigating the health system and managing their conditions. They may have greater access to enhanced benefits, such as telehealth visits, home care after leaving the hospital, and help with co-pays. 
  • The model also requires all REACH ACOs to have a robust plan for meeting the needs of their patients with Original Medicare in underserved communities and make measurable changes to address health disparities.

 

Medicare.gov - Coordinating Your Care

These are the model currently in operation - along with the Direct Contracting Model.  

 

Medicare.gov - Global & Professional Direct Contracting Model ( THIS IS THE ACO REACH Model)

 

I have posted info on each of these models several times - how they work and the benefits and pitfalls of each.  But instead of people looking into these and understanding them - they just take the ‘political” road - According to CMS, the Biden-Harris Administration supports these innovation methods.

It's Always Something . . . . Roseanna Roseannadanna
Periodic Contributor

Thank you for providing this article. Considering AARP is making over $800 million annually by sponsoring Medicare Advantage plans, they will not be informing us of the downsides of such plans or opposing REACH. This serious conflict of interest needs to be communicated by those of us who know about it. Please put the link for this article into any online AARP articles about Medicare. I will do the same.

Honored Social Butterfly

I know a lot of lower income seniors in areas that are lacking in providers and with this system they now have access to total care plus and they love it.  

 

 

 

It's Always Something . . . . Roseanna Roseannadanna
Regular Contributor

Interesting take on a program that just started 15 days before your post.  Personally, I will reserve judgement on any program until it has a meaningful track record.  

According to this comparison chart, ACO REACH only began in 2023 (Plan Year 2023), although providers could sign up last Summer. 

gpdc-aco-reach-comparison

 

While there are some potential benefits (like waiver for 3-day inpatient before Skilled Nursing Home stay for SOME, not all, ACO REACH health systems), there are some real potential negatives (like the substantial decrease in the penalty for not meeting quality of care standards- payment Quality Withhold dropping from 5% to 2%).

Also- currently not all areas are covered by an ACO REACH entity.  Most current list posted to public by CMS is here (Note that States included only means that the entity is operating in at least 1 county in the States)-

aco-reach-py23-participants

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Periodic Contributor

It is my understanding that the program was started under the previous administration under a different name. The Biden administration simply changed the name.

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Regular Contributor

Depends on semantics. Many in the press (and the Administration) have referred to this as a "new model" of care payment & delivery, while others term it a revision of the "Global and Professional Direct Contracting"(GPDC) program of the past 2 years, and still others view it as another modification of the original ACO concept from years before that.  Since its creation by the Obamacare act, the CMS "Innovation Center" has come up with 94 different care payment "models" or programs....most of which have been abandoned.

innovation-models

The CMS chart I linked above shows the differences between the prior GPDC program and ACO REACH. FWIW- CMS views ACO REACH as different enough to be a new program with a new name. Personally I view it as a new program since it means a different provider-controlled governing structure for ACO REACH entities (providers having 75% of governing board voting rights vs only 25% in the old GDPC).  That could be a game changer as providers tend to be in better touch with daily patient care delivery than bureaucrats.  Only time will tell......

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Bronze Conversationalist

@JonRet You are correct. Semantics is used in both the public and private sectors to suggest a "new approach or model" that someone may take credit for. However, sometimes it is a revision of a previous "approach or model" that did not produce the desired results; namely, reduced costs and quality care. 

I will state that many folks enrolled in Traditional Medicare and Medicare Advantage are not aware of the many different payment incentives that have been implemented since Medicare was created in 1965. Some incentives were not successful. For example, there were incentives to encourage providers to affect early discharge from inpatient hospitalizations. In some cases, the quality of the patient's medical status was overlooked. The result was readmission which is not cost effective. 

Your link to Innovation Models provides a wealth of information for readers to "drill down" or "click on. I am not sure if you read through the history and the many past attempts via Congress and legislation to reduce costs and improve care. I suggest readers to click on Innovation Center, then click on "Learn More" which is under the section, The CMS Innovation Center, and scroll down to History of the CMS Innovation Center. 

Readers should also be aware that Congress, in accordance with Section 1115 A of the SS Act, authorized the Innovation Center in 2010 to test innovative payment and service delivery models to reduce Program costs while preserving or enhancing the quality of care furnished to individuals. To me, it looked like Congress was distancing themselves from the difficult challenge of reducing costs and improving care. In other words, implementing a variation of "Managed Care" which worked well in the private sector since the mid 1990s and is still viable today. 

Lastly, if you click on the link, Innovation Models and scroll to the section called Categories, reading each category is important for all readers to know. However, the category that jumps out at me is the last one entitled, Initiatives To Speed the Adoption of Best Practices. It references studies that indicate it takes about 17 years on average before best practices are incorporated into wide spread clinical practice. It does take time.

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