New CMS program to auto enroll those with original medicare into managed care

[testing321]

I just discovered that this started as a pilot program in 2019 and will be expanded to about 31 million people who have original medicare in 2022. Based on who you specify as your primary care physician on medicare.gov or based on data mining your claims, a person on original medicare might be assigned to a managed care entity who will then receive a fixed payment for you and then be responsible for earning a profit by managing your care. The following two links have information about this and if anyone has more information, I would appreciate it. I am concerned that my wife or I might be assigned to such a gatekeeper since we both have a part A, B and D type of Medicare coverage.

https://innovation.cms.gov/innovation-models/gpdc-model
https://www.medpagetoday.com/practicemanagement/reimbursement/95953

 

[MichaelB]

According to this explanation on the Medicare website (here) the primary care physician signs up for the program. It’s directed toward patients that need chronic care, and it looks like individuals are free to continue getting care where they choose. It looks less like a gatekeeper and more like a care manager.

Could this be a small step to move everyone from “pure traditional Medicare” to something more like Medicare Advantage? Yes, but I suspect that is something that would take decades and be more of a risk for my children then for me.

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.

 

[Gotadimple]

According to this explanation on the Medicare website (here) the primary care physician signs up for the program. It’s directed toward patients that need chronic care, and it looks like individuals are free to continue getting care where they choose. It looks less like a gatekeeper and more like a care manager.

Could this be a small step to move everyone from “pure traditional Medicare” to something more like Medicare Advantage? Yes, but I suspect that is something that would take decades and be more of a risk for my children then for me.

This is more about case management in Traditional Medicare than moving folks to a Med Advantage plan.

One of the advantages of Medicare Advantage is that case management is a component that is available and plans get measured on how well the health of beneficiaries with chronic conditions stays stable/improves with case management. That is, a plan could be at a disadvantage with CMS if they aren't attempting to connect a chronic case with case management that can coordinate care. Because plans re-negotiate how much CMS pays them for each beneficiary each year, not providing good quality can affect their renewal.

Cost of care has nothing to do with it in MA, as the cost is on the plan.

But in stand alone case management (sometimes offered in large clinics like the Mayo Clinic) any patient with chronic conditions can qualify to have a case manager who coordinates care between the specialists. The goal is stable improved health (quality of care). A large hospital system or a large clinic system wants to achieve high quality of care awards (because it affects their negotiations for reimbursement with private employer groups, and insurance plans). The metrics are managed, defined, and published by non-profit Quality coalitions not insurers.

 

[Telly]

I just discovered that this started as a pilot program in 2019 and will be expanded to about 31 million people who have original medicare in 2022. Based on who you specify as your primary care physician on medicare.gov or based on data mining your claims, a person on original medicare might be assigned to a managed care entity who will then receive a fixed payment for you and then be responsible for earning a profit by managing your care. The following two links have information about this and if anyone has more information, I would appreciate it. I am concerned that my wife or I might be assigned to such a gatekeeper since we both have a part A, B and D type of Medicare coverage.

There is quite a bit of information available, but one has to dig. It is a large, deep topic, and not for the attention-span limited. It can't be reduced down to a few paragraphs. It's flying so far under the radar, that even observers on the ground have missed it!
It involves government, large sums of $$, and big business insurers and "care" networks. Wherever very large sums of $$ are obtainable, greed and lobbyists are all over it. Then add in a giant dash of politics, and you've got a topic that probably won't make it very far on this website.

The story starts back at least 2015. An "Innovations" group was formed in CMS to look at possible ways of reducing the cost of Medicare FFS. Medicare "FFS" is Fee For Service, the internal name for what we call Original Medicare.

"Experiments" have been conducted, and are ongoing, by the CMS Innovations group on a year-by-year basis. A University has been contracted to keep track of the costs of the experiments, and has issued reports. The reports I have seen, and the conclusion of the University, is that the experimental programs have instead resulted in HIGHER costs to Medicare, not lower! The insurance industry rebuttal is that it is because patients had the ability to change doctors, etc. on their own accord, rather than having to stay in the group. In other words, the insurance industry wants to limit patient choice. Irrespective of the nicey nicey slathering onto the program that you can continue to choose any doctor who accepts Medicare Assignment.
And let us not forget that Medicare Advantage (MA) costs the government more $ per year per person enrolled, than Fee For Service (Original) Medicare! So maybe they really should be studying WHY MA isn't working out financially! But no, big $$ and politics.

I first found out about this earlier this year, in a video by Chris Westfal, who runs Senior Savings Network, an internet broker for medicare policies.
His video here, through about minute 32, covers the basics:

He also references this video, as to why we haven't heard about it, should be big news instead:
https://centerforhealthjournalism.o...porters-used-be-medicare-hounds-what-happened

And I think this video too, which is from March of this year on some details:
https://centerforhealthjournalism.o...gram-could-push-medicare-deeper-private-hands

The large metro area that I live in is one of the "Voluntary Alignment" areas. Oh joy.

Many months ago I made a brief comment on this on ER.org, figuring I would write something up with links and quotes. I never did it. It is too big of a job for me, I'm not a writer. And it would get into greed and politics, verboten here. So I decided not to. Even though this post will be very long, it is nothing compared to the depth (and chicanery), of the topic.

Here are some other links I have found that are worthwhile:

From 2015 CMS, the Next-Gen Accountable Care Organization (ACO):
https://www.cms.gov/newsroom/fact-s...ntable-care-organization-aco-model-fact-sheet

From CMS, the Next-Gen ACO Model:
https://innovation.cms.gov/innovation-models/next-generation-aco-model

From Medicare.gov, the ACOs:
https://www.medicare.gov/manage-your-health/coordinating-your-care/accountable-care-organizations

From CMS Innovation, the Next-Gen ACO model "Voluntary Alignment" Frequently Asked Questions Beneficiaries and Caregivers April 2019:
https://innovation.cms.gov/files/x/nextgenaco-volalignmentfaq.pdf

That one is a real hoot! "Voluntary", uh, my definition of the word is quite different!

On to MY involuntary "Alignment" -- A personal story.
In summer of 2020, I decided to find a new PCP. I had not had one for years, as right before I turned 65, I got a letter from the practice, which had grown from one location to many over the years. They had recently been bought by a big health care amalgamator. The letter said that when I turned 65, the only way I could continue to see them is if I went with one of three MA plans that they serviced. If I didn't, if I went with Original Medicare or some other MA, it was goodbye. This was extremely unusual, taking a few MA plans, but NOT Original Medicare!

In summer 2020, I went to see a doc that was recommended to me, in a small practice. I told the doc about the sales situation, he agreed many were being bought up.

I found the Chris Westfall video earlier this year, and became aware of what CMS was calling the ACO. And this summer, summer of 2021, I received a letter from a "care" organization that owns hospitals and outlying offices. They said that doctor X that I was a patient of, was now part of their ACO, and I was part of their ACO, and that I needed to get on Medicare.gov and put my doc in as my PCP so Medicare could see it. They gave me detailed step-by-step instructions of how to make this selection. Oh yeah, they said I could change my selection any time. Needless to say, I did NOT do that! Nor do I have any plans to. Any hassling me about it, I'll move on.

My Opinion - From everything I have read, I think this is laying the groundwork for insurance companies and large "health care organizations" to get their hands on $$$ that they have limited ability to grab... the Original Medicare folks. They already have the whole MA business, but I think they want their hands on it all. A lot of butter is being smeared around to cover the intent. And they have help from within and without. Anyone who is on Medicare and has read the MA vs. Original Medicare chart in the 2020 Medicare and You publication from CMS, and see the incredibly slanted shill for MA, should not be surprised. They conveniently left out the fact that most Medicare beneficiaries who go Original Medicare, add a Medigap policy, so they are NOT liable for 20% of costs with no maximum!!! I was hoping that the recent change in CMS Director would have killed that nonsense. But it has had years to fester within. My prognosis, folks is, it ain't lookin' good. The names of the programs are being changed, and the target population is expanding fast. It's being sold under a false flag.


Oh, I forgot to add, I don't have chronic anything. I am not, nor have I ever been, on any prescription medication for more than 2 weeks or so, and very infrequently at that. I see no reason that I need to be "managed". If I wanted to be "managed", I would have gone with an MA Plan, a cheap one, probably zero premium, with an HMO, and they would "manage" to save about every dollar out of the $12,000 they would get from CMS to "service" me per-year. No thanks!