ACO-Over-REACH
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Brain Tumor Good News
Glioblastoma is the most common and most aggressive primary brain tumor, with an average survival after diagnosis of less than two years, and against which current treatments remain ineffective. In recent years, immunotherapies have given patients renewed hope, albeit with relatively modest success. A team has succeeded in identifying a specific marker on the surface of tumour cells, and in generating immune cells carrying an antibody to destroy them. Furthermore, these cells, called CAR-T cells, appear to be capable of targeting diseased cells in the tumor that do not carry this antigen, while sparing healthy cells. (Université de Genève)
Psoriasis News
Scientists may have uncovered the root cause of psoriasis, a chronic and sometimes debilitating skin disease that affects 2-3% of the global population. The condition is characterized by red, scaly patches that impact the quality of a patient’s life and can sometimes be life-threatening.
New research, published in NATURE, strongly suggests the hormone hepcidin may trigger the onset of the condition. This marks the first time hepcidin has been considered a potential causal factor. In mammals, hepcidin is responsible for regulating iron levels in the body.
Those most likely to benefit from such a treatment are patients with pustular psoriasis (PP) – a particularly severe and treatment-resistant form of the disease that can affect a patient’s nails and joints as well as skin.
A new treatment targeting iron hormone imbalance in the skin offers hope. This innovative approach could significantly enhance the quality of life for millions, restoring their confidence and wellbeing.
ACO Reach Update
A reader, Sue, asked me to provide an article on ACO-REACH, a Medicare experiment being performed by the Center for Medicare and Medicaid Services (CMS). This is an update to the article I wrote on the subject about year ago. Here is a link to that previous article.
Background
Traditional Medicare (TM)
TM provides beneficiaries the free choice of any doctor or hospital, and reimburses providers at a set rate for their services. Because of TM’s simplicity, the program spends 98% of its funds on patient care, and only 2% spent on administration. Remember, hospitalization, Part A, is mostly covered without monthly payment. Part B, medical, requires a monthly payment. Drug plans and gap plans are purchased separately. Medicare is largely an old style 80/20 co-insurance plan where you pay the 20%.
Medicare Advantage (MA)
MA is run mainly by commercial insurers for profit. The government (Medicare) pays MA insurers via “capitation,” a lump sum per enrollee; then MA insurers must spend 85% of those revenues on patient care, keeping the other 15% as overhead and profit. Taxpayers spend $321 more per year to cover a senior through MA compared to TM. Annual gross profit margins for MA plans averaged $1,608 per enrollee between 2016 and 2018. Remember you make more money by charging more (upcoding) patients and providing fewer services (denials).
Due to fraudulent upcoding, risk scores of enrollees in MA are 19% higher than in TM; causing Medicare to overpay MA insurers by more than $106 billion from 2010 through 2019. We have seen that the top Medicare Advantage providers under Department of Justice criminal investigations for this fraud. That includes for profit and not for profit Medicare Advantage insurers. P.S. Billions of dollars of fraud.
CMS Looking to Save Money
CMS claims to be looking for ways to provide better care at lower cost than Traditional Medicare. They have developed innovative payment schemes for cancer treatments where they pay a fixed amount for treatment, no matter how much treatment you need, That one makes me a little nervous since the facility may be on the hook for more than they receive and you may wind up short changed on treatment. It is listed here in a CMS document - search on oncology to find it.
ACOs are a way some in the government think they can save money.
Accountable Care Organizations
The Direct Contracting (DC) pilot program was developed during the Trump Administration (by a school roommate of Eric Trump’s) to further privatize Traditional Medicare (TM) using some of the same elements as MA. Here is a factsheet on it from PNHP. I recommend it.
There are three basic models for ACOs. They include the Medicare Shared Savings Program (MSSP), the ACO Realizing Equity, Access, and Community Health (REACH), and the Kidney Care Choices (KCC) models. ACO REACH and KCC are both still pilot models under CMS’s innovation arm, CMMI. Combined, these 3 models serve 13.7 million Medicare beneficiaries, which is almost half of all traditional Medicare enrollees.
An Accountable Care organization can be run by any medical facility or by a middleman/private equity interest etc. They essentially create a medical network that will receive payments from the Medicare Trust fund to manage the full care of patients they see.
An ACO REACH organization manages the cost of care for Traditional Medicare beneficiaries who are taking part in this model. CMS pays the ACO REACH management team for the estimated cost of care for beneficiaries that year. The ACO REACH team then pays the providers. What isn’t spent is kept. That is the shared risk part. The MSSP type of ACO offers providers a chance to make extra money by sharing in the savings of keeping patients healthy (or reducing care).
The ACO REACH functions a little like a Medicare Advantage Plan except that you don’t sign up for it. If your doctor is in a practice that has joined one then that is where you are.
While they are allegedly motivated to keep you healthy (they keep more money that way) they are also motivated to have you see their doctors and use their facilities, no matter whether that is in your best interest or not. Again, they keep more money that way.
Providers have to demonstrate quality care but it is really like students grading their own exams. I found they typically gave themselves A’s. They must submit a health equity plan based on a fill-in-the-blank worksheet; which is neither measurable nor enforceable.
Despite the rebranding, ACO REACH has a number of downsides:
Investor-owned middlemen who can pocket much of Medicare payments as profit and overhead;
Automatic enrollment of beneficiaries who must change providers to opt out;
Opportunities to increase profits by “upcoding” and restricting care
The potential to expand privatization to all of Traditional Medicare.
As one industry analyst put it, the ACO REACH rebranding is a “public relations exercise ... that should not tangibly impact the for-profit entities currently participating in the model.”
Here is a link to the Government’s ACO-Reach webpage. You can sign up for regular email updates near the bottom of the page.
Summary
Accountable Care Organizations are another tactic, like Medicare Advantage, to pay others to shoulder the risk of providing insurance. It is an experiment slated to run through 2026 and will likely be allowed to continue afterwards.
It forces Traditional Medicare enrollees into the ACO network of their doctor without their knowledge or approval. The providers in the ACO are incentivized to use their own ACO doctors and facilities as cost saving measures instead of allowing patients the right to shop for what suits them best. The are also incentivized to limit care/treatment to increase the profitability of the ACO.
Patients who find out they are in an ACO (ASK YOUR DOCTOR) can exit the ACO only by finding a new doctor. Depending on where you live this may be nearly impossible.
This is not the Medicare we paid for.
ACTION
Let’s remind those in Congress and the President that CMS is trying to put seniors into Accountable Care Organizations without their knowledge or approval and that those organizations are incentivized to limit care. Seniors can only leave an ACO by changing doctors - they are never informed they are in the network. What kind of bait and switch is this?
Traditional Medicare as a public insurance trust works well, ask anyone who uses it - they can choose any doctor any time. And a public insurance trust is an inexpensive way of insuring a large population because the administration cost is about 2% far less than the 12% to 20% used by commercial insurance. You can reach elected here, https://www.usa.gov/elected-officials.
Or use RESISTBOT via [Apple Messages / WHATSAPP / MESSENGER] or by texting SIGN PTKEOO to 50409 on your cell phone to send that message to our Senators, Members of Congress and the President to stop experimenting with Medicare and putting seniors health at risk.
“I am your constituent and I want you to know that the Center for Medicare and Medicaid Services is once again running the ACO-REACH activity, assigning seniors in Traditional Medicare to Accountable Care Organization networks who are incentivized to limit care. The are assigned without their knowledge and can only leave an ACO by trying to find a new doctor. Good luck with that.
STOP these experiments with healthcare. If you want care that is affordable for everyone pass Universal Healthcare and get it done. Otherwise you are paying organizations run by middlemen and private investors to limit the care seniors get and keep what isn’t spent on care as profits.”
RESOURCES
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Important Healthcare Resources
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Organizations to Contact
National Nurses United Medicare4All
Physicians for a National Health Program
One Payer States
Healthcare Now
Reproductive Health
NARAL - Pro Choice America
Charley. chatbot abortion resource - make sure to use a secure incognito browser if you live in a state that has banned abortion
Planned Parenthood
Miscarriage and Abortion Hotline has references about where to procure abortion medications. They also assist women in the process of self managed abortion or miscarriage by phone or text and will respond in an hour. Details and hours of operation at their website.
United State of Women Reproductive health page (bottom of the page) has important resources such as medical support, access to Telehealth, prescriptions by mail, and legal support references.
Practice careful communications - The Digital Defense Fund has a number of tips to keep texts, calls, and internet use private. Here is their site.
If you need financial help with an abortion try abortionfunds.org
Claims Denials and Appeals & What to Do
Appeal a Healthcare Decision
Appeal/Negotiate a Hospital Bill
Disinformation Management
Cybersecurity Infrastructure Security Agency
Save Democracy
Chop Wood, Carry Water by Jessica Cravens
RESISTBOT
Link to the RESISTBOT site to learn more
Link to Chop Wood, Carry Water RESISTBOT write up
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Thank you, so much, Dr. Unell, for bringing to light this very important and serious issue. I knew you could do a much better job than myself in explaining how Accountable Care Organizations work and their drawbacks. The fact that CMS has been experimenting on traditional Medicare beneficiaries with alternative payment plans that can harm patients without their knowledge or consent since 2010 and often, no alternative, is reprehensible and amoral. This is CMS's way of railroading traditional Medicare beneficiaries into Advantage type plans but behind their backs even though it has been proven over and over that Advantage plans cost Medicare more than traditional. I am glad you pointed out that ACO's are supposedly held to "quality" metrics, but "quality" is neither quantified nor qualified...apparently it is subjective and like you said, every ACO gives themselves "A's." Thank you so much for a great article; now, if only this can make national news, I would be so happy!
Sue
Alan,
Thank you for covering the important ACO topic. The idea of incentivizing providers and patients toward preventive care and not over-utilizing services seems good on the surface but is better described as you did — a bait and switch scheme. Such an “experiment” is an excuse for keeping funding insufficient. Medicare overall pays providers below market rates, so fewer and fewer providers and facilities accept it.
If you start in TM and find access difficult you’re incentivized to enroll in Medicare “Advantage” or supplemental insurance, shifting costs to patients. Now a commercial insurance company adds its administrative costs and ridiculous overcompensation of its c-suite executives. Providers are paid a bit more, so access to care is better some areas but not others.
And we have the complexity and hassle of the Open Enrollment period navigated by elders, the disabled and insurance agents. What an unnecessary and inefficient mess!