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Direct Contracting: Turning Regular Medicare into Medicare Advantage

A recent news article reported on a program that might start to privatize Medicare.  It was started under the former President and is for now being continued by the current President.  I wonder why I haven't seen the usual AARP activism on this topic.  Following are extracts from the article

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At issue is a Trump administration-initiated program that many health-care reformers argue is essentially a backdoor attempt to further privatize Medicare. Almost no one realizes it’s going on — except, that is, corporate interests and private equity investors, who are lined up like pigs at the trough to get their hands on taxpayer dollars.

 

Medicare is administered in one of two ways: traditional fee-for-service Medicare and Medicare Advantage — private insurance offered in place of and through the Medicare system. The dispute is over something called the Direct Contracting pilot program, designed by the Center for Medicare and Medicaid Innovation as a new way of managing benefits in the fee-for-service program. Supporters say it will reduce the amount of money the government spends on traditional Medicare fee for service while improving the quality of patient care.

 

Already, Direct Contracting is increasing the hold of Wall Street and the world of private equity on Medicare. The Centers for Medicare and Medicaid Services say 53 companies have signed up and have been approved to administer the program, which began earlier this year. They are, for the most part, a mix of publicly traded health-care companies and insurers, and private equity backed start-ups.

 

The lure of Direct Contracting for these companies is potential profits. The limits on the amount of money a Direct Contracting entity can keep that’s not used for a patient’s medical needs is significantly more generous than those imposed by Medicare Advantage.

 

And while patients choose to sign up for Medicare Advantage themselves, with Direct Contracting, the primary care doctor, not the patient, enrolls in the program. And why would a doctor sign on? Well, one participant, Clover Health Partners,  says doctors can earn upward of 40 percent more on primary care visits through the program. (When I asked about that, a spokesperson for Clover told me the higher pay did not affect how much Clover earned from Medicare.)

 

Once their doctor is enrolled, patients receive a letter from the Direct Contracting company informing them of their participation. They are assured they are still in Medicare’s fee-for-service program and can still see any doctor they wish in the Medicare program. “Your doctor asked Clover Health Partners to see that you get the right care at the right time,” reads the missive sent out by that company. “We will coordinate your care according to your individual medical needs and treatment choices.” The program will, it adds, “work to reduce duplicate tests and duplicate paperwork that cost you time and money.”

 
The technical term is to say a patient’s care is being “aligned” by the Direct Contracting entity. Heath-care activists use another phrase. “It’s Medicare Advantage by another name but suddenly it’s not voluntary,” Archer says. She argues that doctors in the program can also be incentivized to refer within a particular network or recommend a particular regimen of care. And unlike in Medicare Advantage, the patient won’t necessarily understand that there is a corporate monitor.

 

 

The Biden administration did put at least a temporary stop this year to an even more egregious form of this program which would have auto-enrolled almost all those in Medicare fee for service in a particular preselected geographic area. But CMS, HHS and, ultimately, the White House are continuing to press ahead with Direct Contracting, even though they could end it if they chose.

 

So how could something like this fly so under the radar? Well, the details are very technical, so, many people receiving notice of the change likely didn’t comprehend it. The program itself has not received much attention from the media. And information about it isn’t all that easy to come by. We don’t even know for sure how many people are experiencing “aligned” care; CMS says that data won’t be available till next year.

 

But here’s what we can say: An undetermined number of people enrolled in traditional fee-for-service Medicare are now taking part in an experimental program designed during the Trump administration to increase the role of big business in their medical care. And the Biden administration, which could easily stop this, is instead continuing to enable Trump’s scheme. That’s a big mistake — one that it could easily fix.

 

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Honored Social Butterfly

The approach I am talking about has the Adv. plan replacing Medicare for the Insured. The provider bill the Carrier who pays the provider what Medicare would have paid them. All the provider has to do is be willing to bill the Carrier instead of medicare. These Advantage plans are good nation wide not just in certain areas or limited to their networks.

The Commercials you see promoting benefits like hearing, gym memberships etc are for the most part discount programs the Carrier is using with other insurance programs for employers etc. They just extended them to their advantage programs, and if a person uses them they can save money. Sadly the Carriers promote them as part of medicare to create sales for their plan. A lot of what you see on TV say at the end to call and talk to an agent.

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The new path for Advantage Plans is no restrictions on Dr., Hospitals etc. The provider just bills the Adv. plan instead of Medicare. It is up to the provider if the adv. plan is accepted. Some adv. plans even worked away around that. They tell you to pay the bill and send it to them and they will Reimburse you.

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In theory a reasonable idea. But depending on the ownership of the practice, paying up front is unreasonable.   Case in point: privately run ambulatory care surgery centers owned by the physicians...will not bill. Yep simply will not bill. So an upfront of $40-50 grand  is rather unreasonable. This is for ortho surgery. So seniors are forced to go inpatient or the 23 hours obs amidst rotating covid nurses. I know what I see.  

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@spaniel4 a provider who has opted out of Medicare, or refuses to participate in some/all MA plans has every right to demand up front payment from the patient and let the patient seek reimbursement.

 

Same is true when a patient shows up with one of the "health care sharing" plans, a PPO network only (no insurance) or a straight indemnity plan. My PCP has a sign at the check-in window listing 20+ plans they will NOT accept which also includes Medicaid.

 

(About half the providers in Georgia do not accept ANY Medicaid patients).

 

When someone tells you "this plan is accepted everywhere" don't believe them. They are either lying or have no clue. Same can be said when you are told providers will just bill your carrier  . . .

 

Nope, it does not work that way.

 

There are a lot of folks who think they know how Medicare and insurance works but unless they understand the claim side of things they are shooting blanks.

 

If the provider has opted out of Medicare they are not obligated to file claims for the patient.

 

If the provider participates in Medicare but does not accept ANY MA plans, they MAY file claims with the carrier at their discretion but usually only when they have accepted the TERMS of the MCO agreement.

 

Same is true if the provider accepts SOME of the MA plans but not all plans. This last scenario is quite common in various combinations. The provider MAY accept Humana PPO plans but not the HMO plans.

 

I know an agent in CA that has worked the local Medicare market for almost 40 years and until a year ago there were NO MA plans offered in those zips. The lone MA plan is entering its' 2nd year in that area and only a handful of providers have signed on with them.

 

This shows how things are done in one area does not necessarily mean the same is universally true in other areas.

 

The only reason to ever buy any form of insurance is because you have a reasonable expectation that your claims will be paid. Otherwise all you have is smoke and mirrors.

 


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My reply seems to have gotten lost! So I will try to reply to your post again and thanks by the way. Yea, no smoke and mirrors here. No free lunch for sure. I WAS a provider til pandemic hit hard and I was simply TOO old!. (with all that said here and there I did pro-bono asI am doing now for folks having anxiety regarding transplant issues. Anyway- Here's the deal. The orthopedic surgeon practice has a very well established site in which they talk of their "innovative surgical center. On the site listing the doctors names and credentials is the information regarding the two ambulatory surgical site. My PP Medicare which I have from my spouse is listed. So the ortho surgeons will see you in the office and all is well with the billing and copays,etc etc. However, the surgical site is NOT willing to bill. I do see this as a deceptive advertsing practice. Certainly a practice that this misleading until you get to the point of booking the surgery. Then you get told that the surgical site will not bill and you must go to the inpatient site (or 23 hour site which is in the hospital). My own surgeon is not happy about this so this is by no means a complaint about the provider. And surely I get it after being mired down by a corporate EMR myself in the past with all the regs. But still, confusion regins supreme. A few of my colleagues have switched to cash only in Connecticut as they apparently having a willng client base. they are, however, not surgeons.But this is a scary precedent.

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@spaniel4 for starters, paragraphs are helpful . . .

 

Since you are/were a provider you probably know that each practice and provider has their own unique NPI number. It is not unusual to have an offsite or adjacent site that performs other medical functions such as PT, radiology, surgery, etc.

 

Each practice having their own NPI allows them to decide which carriers and plans they will accept or not. Medicare is unique and it is not unusual for a practice/physician to participate or not in Medicare. I see this with GYN providers where the clinic does not participate in Medicare but some of the individual docs will accept Medicare patients, others will not.

 

There are also cash only providers but, at least in my area, they are generally primary care only. We have concierge practices (again, primary care) that are cash only, no insurance of any kind.

 

To paraphrase from a fast food commercial from a few years ago, this is not Burger King, you can't get it your way, this is the way we do it.

 

It is up to the patient to ferret out the details before going forward and assuming that all providers participate in all plans  . . . and knowing which will bill and which are "no cash, no flash" providers.

 

It does not appear you are asking a question so much as you are taking this space to vent your frustrations. Looking back through this recent post, I don't see any question marks so I am assuming my interpretation is correct.

 

Nothing wrong with blowing off steam, most of us do that from time to time.

 

If you have a problem with the way a provider chooses to conduct business, you will need to adapt to the rules vs expecting them to do it your way.

 

 


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Hello- You are so right, paragraphs are helpful. Right now I have visual impairment secondary to aberrancies with both my cornea transplants.Thus  I am a bit inept with the font I have on now.  (And indeed that's why   I also do some pro bono with transplant folks as a recently retired person.)  I may have mentionned that in a prior post. but, again, sorry for your eyestrain!

 

But I do have to disagree with you on one issue. I don't think I/we have to adapt to a certain "system".I don't need to dumb down my expectations. If I see flagrant deception and/or sidestepping of certain given standards, then I will take my business elsewhere. But you can be sure that I will report the issue to the appropriate board. For example, we should not be accepting a receptionist drawing up meds that is in the purview of a licensed person. (This is an example of something that I will report- as the unlicensed person had no clue of what a "lot "number was). And it is my business, as it is my arm (or IV for that matter).

 

Having worked critical care for decades and in other areas, you can be sure I  know the NPI deal. Surely there is some deception with an orthopedic ambulatory care practice that has our Medicare advantage PPO listed on website for their providers as WELL as for their ambulatory care center which is one elevator floor above. And it is exclusively ortho.

 

But in the end, as you say, this is kind of venting I suppose, gathering my thoughts to head onward for official advocacy which is necessary for seniors. My neighbors have asked me to run for office myself. Please please take this in good humor! Be well.

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@spaniel4 I understand and agree with much of your post(s). So much of health care and health insurance is completely misunderstood by the masses. Unfortunately, there are many (often well intentioned) people who offer advice and really don't understand the complexity of the issue . . . but they jump in any way.

 

As previously stated, the only reason to buy insurance is to have a reasonable expectation your claims will be paid.

 

When someone seeks care, they would like to have a less complicated maze in selecting a provider.

 

Managed care, or as I like to refer to it, mangled care, has made what was once reasonably simple so complicated most folks can't understand what to expect when it comes to their OOP cost. "Hidden providers" are everywhere . . . most often when hospital admission is involved, but also occurs with outpatient procedures.

 

For years I tilted at windmills and got nowhere. Now I take a different path and do my best to educate folks on what to expect and how to minimize their OOP without sacrificing quality care.

 

I also spend a lot of time with clients explaining how claims work, and when a claim is denied, do what I can to help them get the claim paid.

 

ALL my clients have original Medicare and a supplement plan which makes life much easier for them and for me. I spent too much time in the managed care side trying to help folks that fell into a trap because they did not know what to look for and what to expect.

 

Now I get almost no complaints about claims which makes life easier for them and for me.

 

My position is this. Trying to "fix" or change the system is an impossible feat, so I show folks how to navigate the existing system to maximize benefits and minimize costs.

 


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@somarco   The commercials advertising Medicare Advantage are making any confusion so much worse.   Original Medicare and supplement are great if one can afford it.  People turning 65 often do not consider the supplement and down the line they will get stuck in Medicare Advantage. 

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@somarco wrote:  

ALL my clients have original Medicare and a supplement plan which makes life much easier for them and for me. I spent too much time in the managed care side trying to help folks that fell into a trap because they did not know what to look for and what to expect.

 

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Things don't stay simple - I understand the above.  However, let's say your original Medicare client with a supplemental plan thinks they want to go to this group, what would you advise them?

Medicare.gov - Find Healthcare Provider - Tucker, GA. / Doctors / Iora Health

 

This is one of the Direct Contracting providers which this thread was started about - 

 

It's Always Something . . . . Roseanna Roseannadanna
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@GailL1 the link to Medicare.gov is not really comprehensive but the website offers more insight.

 

https://ioraprimarycare.com/

 

Iora Primary Care is a Medicare-participating provider. We accept Original Medicare with or without most Medicare supplement plans. We also accept select Medicare Advantage plans.

To see if we accept your specific insurance plan, contact our Patient Enrollment team.

 

They have not opted out of Medicare . . . they accept patients with Medicare only, Medicare + Medigap and SOME Advantage plans.

 

The practice is multi-disciplinary and "holistic". Primary care only.

 

Recently purchased by OneMedical. No mention of membership fees on the Iora site but OneMedical charges $199 per year.

 

Looks like kind of a "watered down" concierge with the exception that they do take Medicare and some Advantage insurance plans.

 

The ads I have seen and little bit I can find about them screams "we care about you" but it is still a business. I don't know anyone that is a member, so I don't have first hand or second hand input.

 

They will work with the patients existing insurance agent or will refer patients to an agent if they don't have one. That is certainly unique.


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  • I agree it looks like a concierge group that deals directly with medicare. It doesn’t really talk about what they do with ongoing health issues like renal failure or diabetes or cancer or heart disease  or ALS etc… except for counseling. It would be good to know something like that if you were making a choice. 
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@somarco wrote:

 

Recently purchased by OneMedical. No mention of membership fees on the Iora site but OneMedical charges $199 per year.

 

Looks like kind of a "watered down" concierge with the exception that they do take Medicare and some Advantage insurance plans.

 

The ads I have seen and little bit I can find about them screams "we care about you" but it is still a business. I don't know anyone that is a member, so I don't have first hand or second hand input.

 

They will work with the patients existing insurance agent or will refer patients to an agent if they don't have one. That is certainly unique.

==============================

The isn't the same business model as OneMedical had under their own plan.  The business model being used here is the Medicare (CMS) Direct Contracting Model.

Here is a list of them as of May 2021 -

Becker Hospital Review 05/04/2021 - The 53 participants in CMS' direct contracting model (beckershospitalreview.com)

The goals of the model include allowing more types of organizations to participate in risk-sharing arrangements and build off of Medicare ACO efforts like the Medicare Shared Savings Program. 

 

For (lots) more on the CMS (Innovation Center) - Global and Professional Direct Contracting (GPDC) Model

CMS started soliciting signups for this (innovation) program in 2020 - they are supposed to be up and running as of 01/01/2022.  It is a test model - if it works as visioned, more will be added as well as Medicaid managed care organizations.

It is a new way of supplying health care to Medicare beneficiaries, a new way of paying these providers who are linked together under their specific group.

 

The Global and Professional Direct Contracting (GPDC) Model is a set of two voluntary risk-sharing options aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service (FFS), also known as Original Medicare. The goals in designing the GPDC Model include:

  • Create opportunities for a broad range of organizations to participate with the Centers for Medicare & Medicaid Services (CMS) in testing the next evolution of risk-sharing arrangements to produce value and high-quality health care.
  • Build on lessons learned from initiatives involving Medicare Accountable Care Organizations (ACOs), such as the Medicare Shared Savings Program (MSSP) and the Next Generation ACO (NGACO) Model. It also includes innovative ideas from Medicare Advantage (MA) and private sector risk-sharing arrangements.

Do these beneficiaries know that they are within this model?  I don't know.

If it works as visioned - for a time we will probably have:

  • Traditional Medicare
  • Medicare Advantage
  • Direct Contracting - maybe this GPDC model or another, since there are several.

 

It's Always Something . . . . Roseanna Roseannadanna
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@GailL1 you are really getting into the weeds on this one.

 

All I know about Iora or OneMedical is what I see on their respective websites.

 

From my perspective, rarely do the grandiose programs designed by DC think tanks work out as billed.

 

Jonathon Gruber (the "architect" of Obamacare) designed a plan that "relied on the ignorance of the American voter" to succeed. The plan had so many flaws I am surprised it got off the ground . . . and it still is flawed almost 7 years after roll out.

 

DC has access to unlimited funds . . . private industry does not have that luxury. Failed govt programs rarely go away . . . they just continue to morph into something that never lives up to the original billing.

 

My experience with ACO's before and after 2014 was unimpressive. A friend left a good paying job with a major company to go to work for an ACO that, like so many of them, crashed and burned in less than 2 years.


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@somarco wrote

DC has access to unlimited funds . . . private industry does not have that luxury. 

========================

Yep, I do have the habit of getting into those weeds of government

Medicare Advantage plans don't use their own money - they are paid by Medicare.  They make a profit by the way they manage their plans and the beneficiaries within them.

 

When MA plans came into being, they, too, were innovation payment models.  Same is true here.

 

It wasn't that accountable care does not work; it was that the companies administrating them didn't do a good job of managing them and thus several failed.     The model has to be perfected and that is where, IMO, this new innovation method of paying for complete care is headed.  It gets away from the Fee for Service method which is hugely expensive for Medicare and it develops a new way of getting and paying for services.  

 

This one is a blend of medically treating the beneficiaries under an accountable organization method to save Medicare money similar to the way that MA plans make a profit - except in this case, the "profit" isn't a profit but savings to Medicare.

 

Will these work? I don't know - that's the purpose of the experiment. 

I just wanted to let you know that they are out there - they are on the Medicare list of providers accepting "assignment".  They are listed as in-network on some MA plans.  

 

I am just curious as to what processed Medicare EOB will look like.  I found this one - IORA - which is close to my location so I can see if I can follow how it progresses.

 

 

 

It's Always Something . . . . Roseanna Roseannadanna
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They bill in this area.

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But are some actually getting better care????  Medicare could not really control their non-emergency transport - lots of waste, fraud and abuse.  MA plans keep a tight control over who can use it.   Same with DME.

 

Does Medicare want some of these really sick people back in their (Traditional) program.  They certainly go to big (rule) extremes to discourage their return to the Traditional program.  

 

I think getting away from FFS and self-referral in the traditional program would save lots of money but government has little initiative to say no to people but private companies have no problem reigning in cost associated with this.  How does Medicare (traditional) ever prove that a physician is ordering too many test or too many treatments?  How does traditional Medicare confront a beneficiary that is going from specialist to specialist, getting different meds - some of which conflict with the others.  Has traditional Medicare ever said use your primary care doctor instead of a specialist for certain things cause they are very prepared to treat you and it is cheaper for the program. 

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

.

But are some actually getting better care????

 

Are you asking is one healthier with a Medicare Advantage vs. Medicare Supplement plan?

 

I’ve seen all the pros and cons of the two plans but I’ve never seen any statistics that proves one plan guarantees you’ll live longer with them.

 

Bottom line is MA plans are more profitable for the insurance companies and every year it costs taxpayers more per person for Medicare Advantage enrollees than it would have spent for the same beneficiaries had they been covered under traditional Medicare. And it goes up every year.

Honored Social Butterfly

I have been following this since I think mid-2019 when it was 1st being designed by CMS -

I see this as closely related to the ACA's Accountable Care Organizations with the goal of keeping seniors healthier; while supposedly saving Medicare money - win/win

I have even toured one of them around my community - they accept several types of MA beneficiaries as well as Traditional Medicare(FFS) beneficiaries with a supplemental plan.

The area & building was nice, a lot of staff - NP, nurses, health coaches for wellness and for chronic diseases.  Labs were onsite, basic imaging - transportation was provided to appointment for those needing it.  Even occasional social gatherings for seniors.  Classes for seniors, family members and caregivers on nutrition, safety, etc.   

Direct Contracting is a payment model - experimental for 5-years to assess the outcome.  

Personally, I think if a senior lives in an area with lots of other seniors - they will like it - at least the one I looked into.  

 

 

 

It's Always Something . . . . Roseanna Roseannadanna
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@GailL1the Obamacare ACO's didn't fare very well. Most ended up being a money grab by those with DC connections. Taxpayer money funneled into these startups . . . people with little or no background in health care were paid exorbitant salaries to run the organizations . .  most went belly up within 3 years.
 
You might find this STAT News article of interest

 
 

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 These group started before the ACA and the ACA as proposed tried to control this entire area. The extra money for Advantage programs was to be phased  out is an example. You are correct the chain providers have increased costs and decreased care, and should be phased out. Congress came to their rescue and kept them in the picture. The ACA tried to end the extra money they got. No one or group should be allowed to make a lot of money on health care, and that is why we need Medicare for all approach as the current Kovid is showing us, and we have started moving that way in spite of big money.

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