Dear Medicare Enrollees: Yes, Trump is doing...something...with Medicare as well.

There was a bit of confusion on Twitter this morning (shocker!) over a Modern Healthcare story which reported on a new physician payment policy from the Centers for Medicare & Medicaid (CMS) for Medicare enrollees.

At first it looked like CMS was planning on allowing doctors to "balance bill" Medicare patients. Balance billing is already a controversial issue with private insurance; it's the practice of a doctor/hospital charging the patient directly for the difference between what the doctor wants to be paid and what the insurance company agrees to pay them.

On the surface this may not sound like a big deal--after all, co-pays and deductibles already have to be paid by the enrollee, right? However, balance billing refers to additional charges. Let's say the doctor negotiates a price of $1,000 for a procedure with the insurance company, and someone is enrolled in a policy which covers 80% of that. The insurance company pays the doctor $800; the patients pays $200. However, what if the doctor thinks they should actually be paid $1,200? Balance billing means they would charge the patient the additional $200.

I presume it's more complicated than that, but I believe this is what it boils down to. 21 states have laws partially or completely prohibiting balance billing for emergency room or in-network hospital treatment, but the rest don't have any protections on this...and even in the states which do states I'm guessing these rules may only apply to private insurance. I don't believe Medicare or Medicaid have allowed balance billing at all in the past regardless of the state.

The good news is that it turns out that the Modern Healthcare story (paywall) had it wrong:

Correction: An earlier version of this story made an inaccurate reference to balance billing.) The CMS is planning to launch a new pay model that would allow Medicare beneficiaries to contract directly with physicians. Under current law, physicians are paid under a fee schedule in Medicare that includes limits on the amount they can bill beneficiaries per service unless they choose to opt out of Medicare and privately contract with all of their Medicare patients. Private contracting would allow physicians to bill seniors for charges that are more than the rates approved by Medicare.

Unfortunately I don't have access to the full story, and the intricacies of how Medicare works really isn't within my wheelhouse (it's a whole different animal from the individual market, group market and even Medicaid/CHIP). However, Loren Adler of the Brookings Institute lays out the basics:

Should have read the RFI before tweeting, my bad. It doesn't sound like allowing balance billing is what's being proposed, but rather allowing primary care docs to charge M'care patients a fixed fee on top of or in place of typical cost-sharing.

This proposal still means higher costs for many Medicare beneficiaries, reduced government bargaining power, reduced provider access for lower-income benes, & less equity, but it's a long step from allowing balance billing in Medicare.

On the other hand, allowing add'l DPC payments can also mean more services for patients who can afford them. Making it a set fee, not all that different from CPC+, would limit many of the adverse consequences.

For what it's worth, direct provider contracting is still a step in the direction of allowing physicians to charge Medicare patients more than existing cost-sharing amounts, & we know that the previous HHS Sec supported balance billing in Medicare.

If this is limited to the wealthy, it might have some upside in the sense of shifting some of the cost burden from the middle class up to the top...but it also sounds like it could gradually move things even more towards a two-tier healthcare system, with the rich having even more access to better care while the rest of us are treated as second-class citizens. However...again, I don't know enough about this area yet to draw any formal conclusions yet, so I'll leave it there for now.

In the meantime, CMS is requesting public comment on the proposed rule; former CMS Administrator Andy Slavitt is calling for people to contact them here.

Here's the summary from the RFI text itself:

SUMMARY: The Centers for Medicare & Medicaid Services (CMS) currently offers initiatives aimed to improve primary care delivery, beneficiary experience, and accountability for the cost and quality of care. These include the Medicare Shared Savings Program, as well as several Center for Medicare and Medicaid Innovation (Innovation Center) models, including the Comprehensive Primary Care Plus Model, the Next Generation ACO Model, and the State Innovation Models Initiative. CMS is seeking input on direct provider contracting between payers and primary care or multi-specialty group practices to inform potential testing of this approach within the Medicare fee-for-service (FFS) program, Medicare Part C program (also known as Medicare Advantage), and Medicaid (for example via State-based approaches). Direct provider contracting would enhance the beneficiary-physician relationship by providing a platform for physician group practices to provide flexible, accessible, and high quality care to beneficiaries that have actively chosen this type of care model. CMS seeks input from all stakeholders about their experiences with, and perspectives on, direct provider contracting and how CMS can use direct provider contracting models to reduce expenditures and preserve or enhance the quality of care for Medicare, Medicaid, and Children's Health Insurance Program (CHIP) beneficiaries. Additionally, this RFI solicits stakeholder input on how direct provider contracting would interact with, enhance, and/or refine current accountable care organization (ACO) initiatives, such as the Medicare Shared Savings Program.

DATES: Comment Date: To be assured consideration, comments must be received by 11:59 EDT on May 25, 2018.

ADDRESSES: Comments should be submitted electronically to

FOR FURTHER INFORMATION CONTACT: with “RFI” in the subject lin