Why Seniors Like Me Are Fighting Against Medicare Direct Contracting and ACO REACH

When I became eligible for Medicare I had to make the choice between Traditional Medicare and Medicare Advantage (MA), the version of Medicare run by for-profit insurance companies. At first glance, it was a no-brainer: Compared to Traditional Medicare, MA offered additional coverage such as vision, hearing, and dental, with a cap on out-of-pocket expenses. I took the bait and signed up for MA, but soon discovered this was a big mistake.

The Center for Medicare and Medicaid Services has begun to move Traditional Medicare beneficiaries into a program called Direct Contracting, now rebranded as “ACO REACH,” which inserts profit-driven middlemen between seniors and their health care.

A few years passed with no issues, but an old injury progressed to a need for knee replacement surgery. The MA plan required my doctor to submit a request for approval for any referral. I was caught by surprise when the MA plan denied my doctor’s referral to a well-known surgeon, because he was not on their preferred “network”—a decision not based on my health, but on the insurer’s bottom line. I limped along until the end of the year when I switched MA plans to one that covered my chosen surgeon. The fact that a for-profit insurance company could overrule my doctor’s recommendation and my own medical choices was a warning sign that there was a problem with my Medicare choice. And things only got worse.

A couple years later, a small lump on my ear that had been diagnosed previously as benign began to grow and became painful. My primary care provider was concerned about a melanoma, so he quickly submitted a request to refer me to a dermatologist that had been strongly recommended and was in the MA plan’s network. Knowing that early diagnosis and immediate treatment is key to managing melanomas, I became worried when the insurance company hadn’t responded within a couple of weeks.

I called the insurance company and was told that there was no record of this request for authorization. My doctor re-submitted the request. Over the next five months, I made multiple phone calls to the MA insurer, and my doctor again re-submitted the request.

Meanwhile, the lump grew larger and more painful, and I was getting very stressed.

Finally, a customer service representative admitted that the insurer had subcontracted the prior authorization process to another company, and somehow lost the request in the shuffle. This was not very reassuring and I was very anxious.

Nine months after the original request was submitted, I am now recovering from a surgery to remove a malignant melanoma and to search for possible metastases in local lymph nodes. Because of the size and aggressive nature of the tumor, I am being assessed for immunotherapy. If I had been on Traditional Medicare, I could have made the appointment directly with the dermatologist when the symptoms first occurred. I could have potentially avoided major surgery, immunotherapy, and the stress of uncertainty .

I am not alone in this situation. Every day millions of other seniors and adults with disabilities experience denials and delays in needed medical care because MA insurance companies put profits before patients. In a survey by the American Medical Association, a majority of doctors said that prior authorization prolongs illnesses and worsens outcomes for patients. An investigation by the Deptartment of Health and Human Services found that MA plans were inappropriately denying care for patients that would have been approved under Traditional Medicare.

Despite undeniable evidence that Wall Street middlemen drive up costs and deny care, the Center for Medicare and Medicaid Services has begun to move Traditional Medicare beneficiaries into a program called Direct Contracting, now rebranded as “ACO REACH,” which inserts profit-driven middlemen between seniors and their health care. Even worse, seniors who chose Traditional Medicare are being automatically enrolled into this program, without their knowledge or consent.

We can end Medicare Direct Contracting and REACH, but we need everyone to join in.

Direct Contracting/REACH may not be the same as Medicare Advantage, but it’s also sure not the same as Traditional Medicare. At least not when you follow the money. Profits that go into the pockets of investment firms and insurance companies come from taxpayers, and threaten to shrink the Medicare Trust Fund.

We can end Medicare Direct Contracting and REACH, but we need everyone to join in. On Monday, May 23, we’re launching a powerful national movement of seniors, doctors, nurses, and community leaders who are ready to fight back against Medicare profiteering. At our “Turning up the Heat on Medicare Direct Contracting and REACH” event, you’ll hear from seniors like me and also from Congressional leaders such as Reps. Pramila Jayapal and Katie Porter. The event is free and open to all, but you must register in advance HERE.

I learned the hard way. If Wall Street firms are allowed to make decisions about your health care, their profits will always come first. Help me make sure that Medicare puts patients over profits, and join me on May 23.

This content originally appeared on Common Dreams - Breaking News & Views for the Progressive Community and was authored by Rick Timmins.

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