Medicare question: ACO Reach and specialists

[hiker]

I'm a Medicare beneficiary (part A and B) with Federal employee insurance (BCBS) as a secondary payer.

When I was in my 50s, I was diagnosed with a rare form of cancer, originally misdiagnosed at a well-respected hospital overseas, but caught by the path lab at Johns Hopkins and confirmed by the tumor board at UCLA medical center. Before the pandemic, I saw a specialist at Hopkins annually for follow up. I paused all visits since 2020, but am looking to get back to regular follow up. Despite the huge respect I have for JH, I am tired of driving to Baltimore (60 miles) and tired of dodging the squeegee men in downtown Baltimore. While the DC metro area where I live is generally well stocked with specialists of all sorts, the only one I have found with experience with my specific type of cancer is at George Washington University hospital. And all the physician practices at GW are ACO reach practices, as far as I can tell.

I really do not want to be "aligned" with ACO reach, and my primary care physician is not part of a reach practice. My goal is to keep my medical care between myself and my physicians to the extent possible. Perhaps I'm missing something obvious, but I've been unable to find the answer to the question of what happens when your primary care doc is not in ACO reach, but you see a specialist who is. Am I overcomplicating this?

 

[braumeister]

I had never heard of this before, but I found this:
Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model

Maybe you could fill us in on what specifically is the drawback to it?

 

[hiker]

Thanks. I understand how the program works with primary care providers but not with specialists.

My primary objection to ACO Reach is that it puts a profit-driven entity in between me and my medical providers. At age 65 I chose Traditional Medicare in part because I did not want to spend my precious retirement years dealing with insurance companies. That has worked out very well and I don't want to jeopardize it by getting inadvertently sucked into a program that moves me away from the fee for service model that is Traditional Medicare.

 

[MichaelB]

Here’s a short FAQ about ACOs you may find helpful (here)

When you choose a provider that is enrolled in an ACO your Medicare options remain unchanged and you still can see any Medicare enrolled provider you choose.

Regarding the profit motive, I don’t think it is any worse in an ACO than in other parts of our healthcare system. If you do choose an ACO enrolled provider and feel your care or treatment is substandard you can change.

I thought ACOs included primary care physicians. You might call the specialist’s office to confirm they accept patients where the PCP is not enrolled in their ACO.

 

[RetMD21]

I really do not want to be "aligned" with ACO reach, and my primary care physician is not part of a reach practice. My goal is to keep my medical care between myself and my physicians to the extent possible. Perhaps I'm missing something obvious, but I've been unable to find the answer to the question of what happens when your primary care doc is not in ACO reach, but you see a specialist who is. Am I overcomplicating this?

I don't see any how the physician's participation or non-participation affects you. Medicare may share claims data with the ACO but I think you can even opt out of that. The "providers" are trying to qualify for more dollars from Medicare. The ACO is supposedly trying to improve quality but the things being measured are innocuous and mostly have been going on for years without anyone telling you. Link to ACO quality https://www.cms.gov/medicare/medica...o-shared-savings-program-quality-measures.pdf