There appears to be little light any more between corporate health care and government health care or even between government health care-speak and corporate health care-speak. In the latest government push to privatize traditional Medicare–“ACO REACH”–insurer and investor middlemen will responsible for assuming risk and paying claims. The Biden administration claims its goal is “value-based care,” though decades of evidence show that corporate middlemen drive up costs and do not deliver value for patients.
What’s happening? The Biden administration is continuing a Trump administration experiment to pay middlemen–often entities with no meaningful medical expertise–a flat fee per patient to “manage care” for people in traditional Medicare. The administration just renamed the “Global Professional Direct Contracting” experiment–which works like Medicare Advantage–ACO REACH. It will privatize traditional Medicare by turning over “care management” read “money management,” to investors and insurers.
Who will be in the experiment? People with Medicare whose primary care physicians are working for a middleman that contracts with the Centers for Medicare and Medicaid Services as part of “ACO REACH.”
What’s the value to patients? If you look at the role insurer middlemen play in Medicare Advantage, it is hard to see that ACO REACH offers any possibility of value to patients and easy to see huge risk. Given the scant data available in Medicare Advantage, no one can demonstrate value in the care patients receive. MedPAC, the government’s Medicare oversight agency, has never been able to assess care quality in Medicare Advantage plans because the plans have never given it complete and accurate information that would permit MedPAC to assess value. At the same time, government agencies have found widespread and persistent inappropriate delays and denials of care and coverage putting patients at serious health risk.
ACO REACH will offer “care coordination,” but what does that mean? The Center for Medicare and Medicaid Innovation (CMMI) claims the ACO REACH model is somehow going to ensure people in traditional Medicare have their care coordinated in ways that improve health outcomes. But, there is no evidence that people in managed care plans have better health outcomes than people in traditional Medicare. In fact, “care coordination” is often a euphemism for delayed care, less care, and referrals to low-cost providers, none of which is by definition a good thing. Primary care doctors will have financial incentives to minimize costs.
Will ACO REACH promote health equity? CMMI also says it is promoting health equity through ACO REACH, but there’s no evidence to support that claim. Participants will need to have health equity plans. But health equity plans are far different from results and, so long as cost is a barrier to care, it’s hard to see how participants can reduce health disparities. It’s also hard to imagine how CMS will ensure compliance by participants with model requirements.