War of Words Erupts Over Criticism of Medicare Advantage, APMs

Donald Berwick, M.D., and Richard Gilfillan, M.D., published an article in the Health Affairs Blog entitled “Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,’ Part 2: Building on the ACO Model,” in which they criticized in the very strongest terms the new Direct Contracting program under Medicare, the ongoing evolution of the Medicare Advantage program, and some core aspects of the ways in which accountable care organizations (ACOs) are managed in the Medicare Shared Savings Program (MSSP). The Health Affairs blog by Drs. Berwick and Gilfillan was filled with intense criticism of Medicare Advantage of the way in which the MSSP is being run, and most of all, of the new Direct Contracting program. Among their core criticisms: the Medicare Advantage program is essentially providing private health insurance plans with a back door towards privatizing the Medicare program while not adding value, while the entire way in which risk is calculated both in MA and in the MSSP is riddled with errors and problems. The GEO Direct Contracting model was the most extreme, proposing to auto-assign every fee-for-service (FFS) beneficiary in a number of large geographic regions into a fully capitated MA-like “Geo DCE.” Beneficiaries were not given the right to opt out. This was, therefore, straightforward privatization of traditional Medicare, differing from MA only in that GEO Direct Contracting beneficiaries retained the right to see any Medicare provider under standard Medicare coverage.” Risk adjustment,” Crane emphasized, “was designed to estimate a beneficiary’s future health care costs and align compensation with acuity and severity of disease and the related costs of care as complex patients require the use of more resources. The adjusted compensation for high-risk patients provides physicians, healthcare organizations, and health plans resources to create additional programs and services to support and manage patients with important and impactful diseases and conditions