This month, the Biden administration is launching ACO REACH, a program that pits the financial interests of corporate health insurers, private equity firms, and the primary care doctors they employ against the health and well-being of their patients in Traditional Medicare. Is there any chance that REACH will deliver better quality care at lower cost, or even just lower costs without harming quality? More than two million people in Traditional Medicare are at risk.
How does REACH work? The Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, is contracting with middlemen–insurers, private equity and other companies–which assume the risk of keeping health care costs down for people with Medicare. These companies engage primary care doctors (PCPs) to oversee patient care, with the goal of keeping them out of the hospital and away from costly specialty care. If they succeed, the companies can keep 25 percent or more of the savings.
How do REACH entities keep costs down? They incentivize their primary care doctors financially to keep their patients from getting specialty care and other costly health care services. Best case scenario, they keep people from unnecessary hospitalizations and duplicate tests. Worst case scenario, they keep people from getting critical care they desperately need.
How do people enroll in REACH? Generally, they do not. Rather, the Centers for Medicare and Medicaid Services involuntarily enrolls them in the program if their primary care doctors are employed by a REACH entity. If you are enrolled, you should receive a letter letting you know.
How many people are enrolled in REACH? All told, the Biden administration is contracting with 132 health insurers, private equity firms and other entities to “coordinate” care for some 2.1 million people enrolled in Traditional Medicare.
What do these REACH entities know about health care? The Medicare Innovation Center (CMMI), an arm of CMS, claims that it has vetted all the REACH entities to ensure that they understand health care and are invested in the initiative from a quality and cost perspective. At the same time, the Innovation Center’s director, under questioning about how the government protects enrollees from bad actors, said that CMMI could “not draw lines between good guys and bad guys.” Perhaps she misspoke. I hope it does not mean that entities that inappropriately keep people from getting needed care will be able to do so.
What’s the worst case scenario? Primary care doctors keep people from getting the care they need in order to help the REACH entity maximize its profits as well as to maximize their own income. We know from Medicare Advantage that insurers engage in all sorts of fraudulent and wasteful behaviors to maximize their profits. There’s every reason to believe that the REACH entities, including private equity firms and insurers, will engage in the same acts. They know that CMS does not have the resources or the tools or the political will to hold them accountable in a meaningful way for their bad acts.
What can you do to protect yourself if you’re in traditional Medicare? CMS suggests that all the entities with which it has contracted to “coordinate” care will do their jobs well. It also suggests that it will oversee them to make sure that “they don’t stint on care.” Don’t believe that. Question your primary care doctor. Make sure he or she is not part of a REACH entity. If so, make sure your PCP is ensuring you get the care you need. If you’re not sure, you have the right to opt out by leaving your primary care physician and moving to another one. Also, remember that you are still in traditional Medicare, and your care is covered from any doctor or hospital that takes Medicare.
Make your voice heard: Go to protectmedicare.net and sign the petition to President Biden. He can end REACH.
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