‘Medicare Advantage on Steroids’: Advocates Push Back on ACO REACH Model

Home health care providers and Medicare-for-all advocates certainly agree on their general disliking of Medicare Advantage (MA).

The one problem is that these advocates are also fervently against direct contracting in traditional Medicare. And that is an area where many home-based care providers believed they could enter into new, value-based care arrangements either with the federal government directly or through another direct-contracting entity (DCE).

Though there have been a few iterations of direct contracting for traditional Medicare, each has been met with an outcry – no matter the responsible White House administration – putting into question whether these models will ever fully come to fruition as some providers hoped they would.

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“ACO reach is not the same thing as Medicare Advantage. In fact, in my opinion, it is Medicare Advantage on steroids,” Rick Timmins, an active member of the Puget Sound Advocates for Retirement Action (PSARA), said on a virtual event Monday. “But it is not the same as traditional Medicare either, especially when you follow the money. I learned my lesson the hard way. And if Wall Street firms are allowed to make decisions about your health care, their profits will always come first. Your health care will come second.”

The Global and Professional Direct-Contracting Models – creations from the Center for Medicare & Medicaid Innovation (CMMI) under the Trump administration – were halted by the Biden administration. The third, the Geographic Direct-Contracting Model, was completely done away with.

Out of those creations came the Biden administration’s accountable care organization (ACO) “REACH” Model, which stands for “Realizing Equity, Access and Community Health.” That model was announced earlier this year with its self-referential dedication to creating more equity in the direct-contracting program. It is set to launch on Jan. 1, 2023.

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Participants on the virtual event, dubbed “Turning up the heat on REACH and DCEs,” ranged from active lawmakers to senior care advocates from across the country.

The MA comparison is something home health providers will understand, at the very least. The anti-direct-contracting advocates see MA entities as profit-hungry actors in the health care space that deny claims and de-prioritize patient health.

If they also believe that to be true, seniors can opt for traditional Medicare in lieu of MA. But Timmins and the other activists argue that direct contracting threatens that as well, as seniors can be entered in direct contracting agreements without their consent, they say.

“They have the authority to assign seniors and people with disabilities into a DCE or REACH without your full knowledge or consent,” Dr. Ed Weisbart, the Missouri chair for the Physicians for a National Health Program (PNHP), said. “So you still have Medicare, but now Medicare pays the DCE or the REACH [ACO], and the DCE or REACH ACO pays your doctor or hospital. And the DCE keeps nearly all of what they don’t spend on your health care. So for the first time ever, there is a middleman in traditional Medicare making a profit from your health care.”

Direct-contracting advocates would push back hard against these sentiments, as would some other lawmakers. There are plenty of home-focused DCEs, for example, that see this as a way to improve the Medicare program by shifting care from a fee-for-service model to one more focused on value.

Generally, direct contracting has received bipartisan support.

“I’ve actually been really surprised by the bipartisan support for direct contracting,” Francois de Brantes, the SVP of commercial business development at Signify Health (NYSE: SGFY), told Home Health Care News last year. “At the edges, you always have people who either don’t have a full understanding of a program or who are critical for the sake of being critical.”

The Dallas-based Signify Health is a health care platform that leverages analytics, technology and provider partner networks to both create and aid value-based payment programs. 

Home-based care providers themselves have also been enticed by the opportunity to engage with already-approved DCEs.

But the very idea of value-based care has also been called into question of late. Not that “value” over fee for service is a bad thing, specifically, but that providers may be prioritizing the wrong aspects of their businesses to attain that value.

“The ACO REACH program is Medicare privatization, hidden in layers of bureaucracy,” U.S. Rep. Pramila Jayapal (D-Wash.) said Monday. “Essentially, seniors are put into this program, which allows a profit-seeking third party like a health insurer or private equity-backed firm to step in and get paid by Medicare to manage the care that they get. Taking for themselves the profit that is whatever they don’t want to spend on the patient.”

PNHP and the other stakeholders on the call – including U.S. Rep. Katie Porter (D-Calif.) – urged both individuals and other senior organizations to join the fight against ACO REACH, and are readying up for an especially hard push by July 30 – the Medicare program’s 47th anniversary.

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