Docs Come to D.C. to Protest Medicare's Direct Contracting Program - MedPage Today

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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.

"We all benefit when everyone has access to healthcare," said Susan Rogers, MD, PNHP's president and a retired internist from Chicago. "And the only way to do that is to have a system that does not include profit margins or shareholder dividends disguised as a middleman. We cannot allow the ongoing onslaught of privatization with these direct contract entities."

The direct contracting program, which began under the Trump administration, "creates opportunities for a broad range of organizations to participate with the Centers for Medicare & Medicaid Services (CMS) in testing the next evolution of risk-sharing arrangements to produce value and high quality healthcare," according to a CMS fact sheet. "The payment model options available under direct contracting also leverage innovative approaches from Medicare Advantage and private-sector risk-sharing arrangements."

The program, which includes three different types of direct contracting models, will offer "both capitated and partially capitated population-based payments that move away from traditional fee-for-service" and seeks to broaden participation "by allowing model participation by organizations new to Medicare fee-for-service, such as physician managed organizations that currently operate exclusively in the Medicare Advantage program ... and innovative, new organizations that seek to assume responsibility for Medicare fee-for-service beneficiaries in a geographic target region," according to CMS.

"We cannot allow the ongoing onslaught of privatization with these direct contract entities," said Susan Rogers, MD, president of Physicians for a National Health Program (PNHP), at a rally outside HHS. (Photo courtesy of PNHP livestream)

This is bad news for the program on several fronts, PNHP members say. First, it allows insurers and other commercial entities to enter the Medicare fee-for-service market. "I personally used to think it was a great idea" to let for-profit entities get involved in healthcare, PNHP board member Ed Weisbart, MD, a retired family physician from St. Louis who attended the rally, said in a phone interview Monday.

"I went to medical school because I loved the idea of having financial interests aligned with making us healthier; I thought that was a great idea ... And I worked inside the managed care industry for years and years because I really did think that. But what I actually learned was that that's the opposite of the truth. In reality, when you have a for-profit entity in charge of your health, the best way to make money is to impede the care of people who are sick with high-end, expensive illnesses," Weisbart said.

Another problem is the program's "auto-enrollment" feature, he continued. "The way this is set up is for CMS to data-mine their claims and find -- or think they find -- your primary care physician. And if your primary care physician has signed a contract with a direct contracting entity, they will automatically capitate the direct contracting entity for your care, and you won't be told that. Or you might be told that, but it will be a typical bureaucratic letter that will say at the very top, 'You don't need to take any action about this.' So you might get a letter, but you certainly won't be asked for your approval. If you actually learn about it and decide you don't like the idea, there is no opt-out alternative. You can't get yourself out of this."

Melinda St. Louis, director of Public Citizen's Medicare for All program, agreed. "This direct contracting experiment could lead CMS to auto-assign as many as 31 million people involuntarily to a Medicare Advantage-type health plan that they specifically opted not to join when they signed up for traditional Medicare," she said at the rally.

"This is an unacceptable 'bait and switch' that presents real threats to people enrolled and to the Medicare program overall. With private insurers and the for-profit investors in the program, maximizing revenues, not quality of care, will become the central focus, and that is the problem with our current broken, expensive, and cruel healthcare system," St. Louis said.

As many as 31 million Medicare beneficiaries could be automatically enrolled in a direct contracting entity without their knowledge or consent, said Melinda St. Louis, director of Public Citizen's Medicare for All program. (Photo courtesy of PNHP livestream)

Currently, 53 direct contracting entities -- including physician practices, health systems, and insurers, have signed up for the program, "but there are six [entities] that are really big ones," with the vast majority of potential members, Weisbart said. "And those six are all insurance company-owned."

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.

"Their department knew we were coming; we had made multiple phone contacts with them," said Claire Cohen, MD, a child psychiatrist from Pittsburgh. "Despite that, when we got in, we were not able to deliver our petitions."

Asked to comment on the group's concerns, a CMS spokesperson referred to text on the agency's direct contracting fact sheet saying among other things that "Medicare beneficiaries can continue to see any health care provider they choose and will not lose any of their existing benefits;" the spokesperson added that "Just like prior ACO [accountable care organization] initiatives, beneficiaries may also be aligned based on their historical usage of primary care services. All aligned beneficiaries receive an annual notification."

HHS did not respond to a question about why the group's petitions were declined.

Last Updated December 01, 2021

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  Joyce Frieden oversees MedPage Today’s Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow

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