There’s a slow-rolling theft going on right under our noses, instigated by the Trump administration and yet not stopped by Biden (so far, anyway). The Center for Medicare and Medicaid Innovation started a new direct contracting model under Trump that essentially expands Medicare Advantage without many of the price controls present in that system to unwitting seniors who may have even deliberately signed up for traditional Medicare.
Thanks to The Intercept for seemingly being the only one highlighting this fraud:
The direct contracting model was announced publicly in April 2019 and began its implementation phase in October 2020. The project pays private companies a predetermined but individualized amount per year, per patient, regardless of what the company spends on care, and has persisted and grown under the Biden administration.
Career staff were not amused:
In May 2019, a calendar alert went out to staff reading “discussion with Landmark on the direct contracting model.” Career staff were appalled. “This shit is so fucking gross,” wrote one in a group text with other aides which was shared with The Intercept. “Ugh. What the fuck,” replied another, with a third sending a link to the Office of the Inspector General, suggesting it be reported. (It does not appear to have been reported.)
The payment model is designed to be lucrative for firms contracting with the government: The government pays a set amount of money annually per patient based on a risk score that is easily gamed by the health care company, and there is no requirement that a minimum percentage of the money be spent on care, a requirement known as a “medical loss ratio” that is typically used to constrain insurance firms or providers from eating the bulk of the funding.
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Direct contracting uses a model that, in theory, pays firms for maintaining the overall health of a patient rather than billing Medicare for individual medical services. Critics argue that the latter model, which is currently used for standard Medicare enrollees, incentivizes unnecessary hospital visits and treatments. But the former model, which is referred to as value-based contracting, requires complex bureaucratic oversight to ensure that providers are not juking the system by unreasonably inflating the cost and difficulty of caring for a patient.
Just a couple weeks ago, doctors protested this program in DC:
WASHINGTON -- Medicare's direct contracting program, if it is allowed to continue, will be the end of traditional Medicare, a physician group said here Tuesday.
Two dozen members of Physicians for a National Health Program (PNHP), which supports a single-payer healthcare system, and other healthcare groups attended a rally in front of the Department of Health and Human Services (HHS); they brought with them petitions to HHS Secretary Xavier Becerra asking him to stop the program.
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The group brought petitions signed by 13,000 people, including 1,500 physicians, asking for the program to be stopped. However, they were not allowed to present their petitions to the HHS secretary, and no one at the building's reception desk would accept them.
Thankfully, we can count on Pramila Jayapal to be on the ball. From her op-ed in The Hill an explanation of how seniors can b moved to this program without their knowledge or consent:
A majority of seniors choose Traditional Medicare over Medicare Advantage, the version of Medicare run by commercial insurers, because they value having free choice of providers and the power to manage their own care. But under the Medicare Direct Contracting program, older Americans who actively chose the popular Traditional Medicare program are automatically enrolled into a Direct Contracting Entity without their full knowledge or consent.
Seniors in Traditional Medicare may be “auto-aligned” to a DCE if any primary care physician they’ve visited in the past two years is affiliated with that DCE. That means Medicare automatically searches two years of seniors’ claims history without their full consent to find any visits with a participating DCE provider as the basis for enrollment. It’s no wonder that the current DC pilot phase includes potentially 30 million Traditional Medicare beneficiaries enrolled in 53 DCEs across 38 states.
The big question here is why are Biden and Bacerra allowing this to continue? This story has gotten little to no coverage in the mainstream media, so it’s possible it has largely flown under the radar until now, however this cannot be allowed to remain the case. However, that doesn’t answer the question of why the doctors in the story above weren’t even allowed to present their petition.
It seems only Daily Kos staff has the ability to create an action linked to a story, but this one certainly calls for it. Everyone needs to contact their members of Congress and demand an investigation of this and demand that this theft from the people be ended post-haste.
Contact your senators and representative today:
Contact your senators
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Contact the White House